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I 


TYPHOID    FEVER 

ITS    CAUSATION,    TRANSMISSION  AND 

PREVENTION 


WORKS   OF  G.   C.   WHIPPLE 

PUBLISHED   BY 

JOHN    WILEY   &    SONS. 


The  Microscopy  of  Drinking=water. 

Second  edition,  revised.  8vo,  xii  +  338  pages, 
figures  in  the  text  and  ig  full-page  half-tones. 
Cloth,  $3.50. 

The  Value  of  Pure  Water, 

Large  i2mo,  viii+  84  pages.      Cloth,  $1.00. 

Typhoid  Fever  — Its  Causation,  Transmission  and 
Prevention. 

Introduction  by  William  T.  Sedgwick,  Ph.D. 
Large  i2ino,  xxxvi -1- 407  pages,  50  figures.  Cloth, 
^3.00  net. 


Digitized  by  the  Internet  Arciiive 

in  2010  witii  funding  from 

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http://www.archive.org/details/typhoidfeveritscOOwhip 


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TYPHOID  FEVER 

ITS    CAUSATION,   TRANSMISSION   AND 
PREVENTION 


BY 

GEORGE   C.  WHIPPLE 

CONSULTING    ENGINEER 
WITH 

AN    INTRODUCTORY    ESSAY 

BY 

WILLIAM    T.  SEDGWICK 

PROFESSOR    OF    BIOLOGY,    MASSACHUSETTS    INSTITUTE    OF    TECHNOLOGY 


FIRST  EDITION 
FIRST    THOUSAND 


NEW    YORK 

JOHN   WILEY   &    SONS 

London:   CHAPMAN   &   HALL,   Limited 

1908 


Copyright,  1908, 

DY 

GEORGE  C.  WHIPPLE 


Stanbope  ipresa 

F.    H.  GILSON     COMPANY 
BOSTON.     U.S.A. 


To 

THE  MASSACHUSETTS   INSTITUTE    OF    TECHNOLOGY 

My    Alma   Mater 
A  Piont;er  in  Sanitary  Education 

ENTITLED  TO  THE  GRATITUDE  OF  EVERY  ONE  WHO  VALUES 

THE  PUBLIC  HEALTH 


K 


PREFACE. 


Few  people,  according  to  vital  statistics,  die  of  old 
age;  almost  every  one  dies  of  disease;  and  when  your 
turn  and  mine  shall  come  to  shuffle  off  this  mortal 
coil,  we  shall  have  the  unwelcome  and  involuntary 
lot  of  more  than  two  hundred  different  diseases. 

The  human  body  is  a  machine.  Occasionally  it  is 
put  together  wrong;  the  various  parts  do  not  work  in 
harmony.  More  often  the  machine  is  improperly 
operated;  it  is  driven  too  fast,  or  it  is  given  too  much 
fuel,  or  not  enough.  Derangements  due  to  these 
internal  causes  are  termed  "constitutional"  and  "local" 
diseases.  There  is  another  group  of  diseases  which 
attack  the  body  from  without.  They  are  the  infectious 
diseases,  or  contagious  diseases,  parasitic  diseases, 
zymotic  diseases,  as  they  are  variously  called.  Alike  in 
the  fact  that  they  are  all  caused  by  living  organisms, 
they  differ  in  many  ways.  The  organisms  themselves 
are  different.  Each  has  an  individuality  of  its  own, 
which  the  bacteriologist  has  come  to  recognize  and  to 
understand.  There  are  differences  in  biological  character, 
in  habitat,  in  mode  of  development,  in  means  of  trans- 
mission, in  the  manner  of  attacking  the  body,  in  viru- 
lence, in  longevity,  in  powers  of  resistance  against 
remedial  measures. 

ix 


X  PREFACE. 

But  the  human  body  is  more  than  a  machine;  it  is  an 
organism  of  living  cells,  each  a  living  entity,  and  each 
working  for  the  good  of  all.  Invaded  by  cells  from  with- 
out, a  mortal  struggle  takes  place  within  the  body.  The 
enemy,  though  microscopic  in  size,  and  fighting  with  the 
aid  of  insidious  toxins,  has  often  been  the  victor;  but, 
thanks  to  the  science  of  bacteriology  and  its  influences 
in  the  arts  of  healing  and  of  public  sanitation,  the 
terrible  ravages  of  the  infectious  diseases  known  in 
former  days  have  been  checked,  and  all  along  the  line 
there  has  been  marked  progress  in  combating  the  bac- 
terial foes.  How  great  the  value  of  the  modern  sanitary 
arts  is  to  the  welfare  of  the  human  race  is  seldom  realized, 
yet  the  vital  statistics  published  year  after  year  are 
filled  with  proofs  that  diseases  are  gradually  lessening 
and  that  the  span  of  human  life  is  lengthening. 

Among  the  infectious  diseases  few  are  more  dreaded 
by  the  general  public  than  typhoid  fever.  Although 
less  common  and  less  dangerous  than  many  diseases, 
yet  because  of  its  insidious  invasion,  its  prolonged  run 
of  fever  and  prostration,  its  frequent  epidemic  character, 
and  its  too  frequent  fatal  ending,  typhoid  fever  has 
come  to  occupy  almost  the  first  place  in  popular  thought 
among  the  diseases  of  mankind.  People  have  come  to 
recognize,  too,  that  it  is  one  of  the  preventable  diseases, 
and  that  whenever  a  case  of  typhoid  fever  occurs  some- 
body has  been  at  fault  somewhere.  All  this  has  naturally 
given  rise  to  many  misconceptions,  —  not  only  among 
the  laity,  but,  unfortunately,  among  members  of  the 
medical  profession.  Many  true  theories  have  been  over- 
worked, many  accurate  bits  of  bacteriological  evidence 


PREFACE.  XI 

have  been  unduly  exaggerated,  unproven  statements 
have  been  given  currency,  while  some  of  the  less  tech- 
nical but  more  practical  matters  have  been  undervalued 
or  almost  entirely  overlooked.  As  an  illustration  of 
this  situation  we  may  take  the  current  opinion  of  the 
nature  of  the  disease,  —  its  infectious  character  has  been 
so  much  emphasized  that  the  fact  that  it  is  contagious 
as  well  as  infectious  has  been  quite  neglected. 

The  fight  against  typhoid  fever  must  be  made  largely 
by  men  of  two  professions,  by  physicians  and  engineers. 
Differences  in  temperament,  in  training,  and  in  the 
nature  of  their  work  have  prevented  these  two  profes- 
sions from  cooperating  as  closely  as  they  must  if  typhoid 
fever  is  to  be  relegated  to  the  class  of  infrequent  diseases. 
The  doctor  naturally  thinks  of  men  as  individuals;  he  is 
not  accustomed  to  think  of  men  in  masses.  The  sanitary 
engineer,  with  his  genius  for  mathematics  and  statistics, 
studies  communities  at  large,  and  is  in  danger  of  neglect- 
ing to  study  the  details  of  particular  cases.  The  two 
professions  admirably  supplement  each  other.  The 
engineer  is  by  training  the  best  fitted  to  control  the 
measures  which  are  instrumental  in  warding  off  the 
disease,  to  deal  with  matters  of  water-supply,  sewage 
disposal,  and  the  other  sanitary  arts;  while  the  physician 
is  best  fitted  to  attack  the  disease  in  the  household. 

The  object  of  this  book  is  to  furnish  to  the  members 
of  these  two  professions  a  condensed  summary  of  the 
most  important  facts  that  have  been  learned  regarding 
typhoid  fever,  so  far  as  they  relate  to  the  prevention  and 
spread  of  the  disease;  to  furnish  to  the  student  of  sani- 
tary science  a  group  of  illustrations  of  some  of  the  leading 


xii  PREFACE. 

principles  of  epidemiology;  and  to  give  to  the  general 
reader  a  simple  and,  it  is  hoped,  a  clear  and  correct 
account  of  the  causation,  transmission  and  prevention 
of  the  disease,  and  his  own  responsibility  in  helping 
to  bring  about  such  conditions  of  cleanliness  that 
typhoid  fever  shall  soon  cease  to  be  a  national  disgrace. 

New  York,  April.,  1908. 


ACKNOWLEDGMENTS. 


The  author,  being  more  familiar  with  the  engineering  side  of 
his  subject  than  its  other  phases,  has  been  compelled  to  invoke 
the  aid  of  his  many  friends  in  the  medical  profession  in  the 
preparation  of  this  book.  To  all  of  them  he  wishes  to  express 
his  thanks,  and  in  particular  to  Dr.  Herbert  D.  Pease,  Director 
of  the  State  Hygienic  Laboratory  of  the  New  York  State 
Department  of  Health ;  Dr.  E.  C.  Levy,  Chief  Health  Officer, 
Richmond,  Va. ;  Mr.  Francis  F.  Longley,  Chief  Chemist  and 
Assistant  Superintendent  of  the  Washington  Aqueduct  Filtra- 
tion Plant ;  and  to  his  own  family  physician,  Dr.  A.  Ross 
Matheson,  of  Brooklyn,  N.Y. 

He  is  also  under  obligations  to  many  others,  who,  because  they 
are  many,  must  here  be  nameless,  —  to  authors  of  various 
memoirs  from  which  quotations  have  been  freely  made,  some- 
times, perhaps,  with  too  scant  acknowledgment;  to  health 
officers  in  many  cities  both  in  this  country  and  abroad,  who 
have  contributed  typhoid  statistics;  and  to  his  nearer  pro- 
fessional friends  and  associates  who  have  given  advice  and 
assistance  in  many  ways. 

And,  finally,  to  Prof.  WiUiam  T.  Sedgwick,  of  the  Massa- 
chusetts Institute  of  Technology,  from  whom  the  author 
received  his  first  lessons  and  acquired  his  first  interest  in  the 
science  of  epidemiology. 


zui 


CONTENTS. 


CHAPTER   I. 
TYPHOID   FEVER. 

PAGE 

Typhoid  Fever.  —  Symptoms.  —  Tj'pical  Case.  —  Treatment.  — 
Complications.  —  "Walking"  Cases.  —  Allied  Diseases i 

CHAPTER   II. 

BACTERIOLOGY  OF  TYPHOID  FEVER. 

The  Typhoid  Bacillus.  —  Specific  Cause  of  the  Disease.  —  Portals 
of  EntT}'.  — •  Multiplication  in  the  Body.  —  Typho-toxin.  — 
Natural  Defenses  of  the  Body.  —  Widal  Test.  —  Blood  Tests.  — 
Modes  of  Exit.  —  Typhoid  Carriers 8 

CHAPTER   III. 
THE   TYPHOID    PATIENT   AS   A   FOCUS    OF   INFECTION. 

The  Endless  Chain.  —  Barriers  Against  the  Spread  of  the  Disease. 

—  Vehicles  of  Infection. —  Contagion.  —  Duty  of  the  Physician. 
—  Duty  of    the    Nurse.  —  Disinfection.  —  Report   to   Board    of 

Health.  —  Duty  of  the  Household.  —  Disinfectants.  —  Dis- 
posal of  Fecal  Matter.  —  Cleanliness.  —  Isolation.  —  Children. 

—  Dut^'  of  Public  Authorities.  —  System  of  Reporting  Cases.  — 
Blood  Tests.  —  Supervision  over  Disinfection.  —  Sewage  Dis- 
posal. —  Disposal  of  Fecal  Matter  on  Boats  and  Trains.  — 
Care  of  Toilet  Rooms.  —  Flies 21 


xvi  CONTENTS. 

CHAPTER  IV. 
THE   TYPHOID    BACILLUS   AT   LARGEo 

PAGE 

The  Typhoid  Bacillus  Outside  the  Body.  —  Requirements  for 
Growth.  —  Moisture.  —  Sunlight.  —  Temperature.  —  Food.  — 
Longevity  in  Water.  —  Decrease  of  Bacilli  in  Water.  —  The 
Resistant  Minority.  —  Longevity  in  Sewage.  —  Decrease  of 
Bacilli  in  Sewage.  —  Fate  of  Bacilli  in  Cesspools.  —  Efficiency  of 
Sewage  Purification.  —  Self  Purification  of  Streams.  —  Effect 
of  Dilution.  —  Sedimentation.  —  Time.  —  Aeration  and  Oxida- 
tion. —  Present  Status  of  Theory  of  Self  Purification  of  Streams. 

—  Self  Purification  of  Lakes  and  Reservoirs.  —  Dispersion.  — 
Sedimentation.  —  Beneficial  Influence  of  Storage.  —  Antagon- 
ism of  Microscopic  Organisms.  —  Dangers  of  Depending  upon 
Storage  Alone.  —  Self  Purification  in  Conduits  and  Pipes.  — 
Dead  Ends.  —  Longevity  in  Ice.  —  Natural  Ice.  —  Artificial  Ice. 

—  Handling  of  Ice.  —  Longevity  in  the  Soil.  —  Longevity  in 
Milk.  —  Longevity  in  Oysters. —  Longevity  in  Flies. — Longevity 

on  Fabrics 41 

CHAPTER   V. 

LINES   OF    DEFENSE   AGAINST   THE    TYPHOID   BACILLUS 

Co-operative  Work  Necessary.  —  Public  Responsibility.  —  Value 
of  Statistics.  — Public  Water  Supplies.  —  Filtration  Increasing. 

—  Standards  of  Purity  Rising.  —  Safety  of  Ground  Waters.  — 
Dangers  from  Surface  Waters.  —  Sanitary  Supervision  of  Water- 
sheds. —  Effect  of  Filtration.  —  Vended  Waters.  —  Dangers 
from  Dirty  Milk.  —  Certified  Milk.  —  Pasteurized  Milk.  — 
Regulation  of  Oyster  Culture.  —  Supervision  of  Food  Supplies. 

—  Educational  Work.  —  Household  Responsibility.  — •  The 
Country  Well.  —  Boiling  the  Water. —  House  Filters.  —  Pas- 
teurization of  Milk.  —  Screening  the  Windows.  —  Personal 
Responsibility.  —  The  Health  Tone.  —  Risks  of  Traveling.  — 
Nostrums 69 

CHAPTER   VI. 
TYPHOID   FEVER   STATISTICS. 

Nature  of  Statistics.  —  Death  Rates.  —  Sources  of  Error.  — 
Morbidity  Statistics.  — ■  Sources  of  Information 92 


CONTENTS.  xvii 

CHAPTER   VII. 
DISTRIBUTION   OF   TYPHOID    FEVER. 

PAGE 

Age.  —  Sex.  —  Racial.  —  Occupation.  —  Rural  and  Urban.  — 
Climatic.  —  Geographical.  —  Geological.  —  Hydrographic.  — 
Seasonal.  —  Vacation  Typhoid.  —  Chronological.  —  Spanish 
War.  —  Causes 103 

CHAPTER   VIII. 

TYPHOID    FEVER    EPIDEMICS. 

Classification  of  Epidemics.  —  Plymouth.  —  New  Haven.  — 
Ithaca.  —  Scranton.  —  Lowell  and  Lawrence.  —  Waterville 
and  Augusta.  —  Pittsburg  and  Allegheny.  —  Chicago.  — 
Cleveland.  —  Burlington.  —  Butler.  —  Lowell,  1902.  —  Milli- 
nocket.  —  Baraboo.  —  Great  Lakes  Steamer.  —  Lausen.  — 
Basingstoke.  —  Newport.  —  Auxerre.  —  Trenton.  —  Mount 
Savage.  —  New    Haven    Jail.  —  Winnipeg.  —  Military  Camps. 

—  Japanese- Russian  War.  —  Somerville.  —  Springfield.  —  Stam- 
ford. —  Marlborough.  —  Waterbury.  —  Montclair. —  Wesleyan. 
— Winchester.  —  Southampton.  —  Lawrence.  —  Springfield,  1 905 , 

—  Ogdensburg.  —  Special  Characteristics.  —  Warnings.  —  In- 
fection Widespread.  —  Epidemics  as  Life  Savers 134 

CHAPTER   IX. 
INVESTIGATION  AND  CONTROL  OF  TYPHOID  FEVER  EPIDEMICS. 

Collection  of  Data.  —  Study  of  Data.  —  Control  of  Epidemics    .      216 

CHAPTER   X. 

INFLUENCE    OF   PUBLIC    WATER   SUPPLIES   ON   THE    TYPHOID 
FEVER  DEATH  RATES  OF  CITIES. 

Frankfort-on-the-Main.  —  Newark.  —  Jersey   City.  —  Cleveland. 

—  Lowell.  —  Zurich.  —  Hamburg.  —  Lawrence.  —  Albany.  — 
Binghamton.  —  Watertown.  —  Paterson.  —  Paris.  —  St.   Louis. 

—  Philadelphia.  —  Benefits  of  Filtration.  —  Youngstown.  — 
Washington.  —  Boston.  —  New  York.  —  Brooklyn.  —  Balti- 
more. —  Lorain.  —  Stream  Pollution 228 


xviii  CONTENTS. 

CHAPTER  XI. 

EFFECT  OF  MILK  SUPPLIES  ON  THE  TYPHOID  FEVER  DEATH 
RATES  OF  CITIES. 

PAGE 

Glasgbw.  —  Liverpool.  —  Washington.  — ■  German  Cities  .    .    .    .     267 

CHAPTER  XII. 

THE  FmANCLA.L  ASPECT. 

Financial  Value  of  Life.  —  Cost  of  Typhoid  Fever  to  txie  Country. 
—  Effect  of  Filtration.  —  Effect  of  Contamination.  —  Con- 
clusion    273 


APPENDICES. 


Appendix 

I. 

Appendix 

II. 

Appendix 

III. 

Appendix 

I^'. 

Appendix 

A'. 

Appendix 

\1. 

Appendix 

\11. 

Appendix 

\111. 

Appendix 

IX. 

Appendix 

X. 

Appendix 

XI. 

Appendix 

XII. 

Appendix : 

xin. 

Appendix 

XIV. 

Appendix 

XV. 

Appendix '. 

X\1. 

FACE 

The  Use  of  Disinfectants 287 

House  Flies.     From  paper  of  Dr.  L.  O.  Howard  .  296 

The  Estimation  of  Population 303 

Corrected  Death-rates 307 

Bacteriological  Description  of  B.  tj'phi 314 

Tests  for  Diagnosis  of  Typhoid  Fever.    (Circular 
of  Information  of  Department  of  Health,  Cit}' 

of  New  York.) 317 

Bacteriology    of    the    Blood.     By    Dr.    Warren 

Coleman  and  Dr.  B.  H.  Buxton 322 

Examination  of  Water  for  B.  t}'phi 332 

Water  Analysis   and  Investigations  of  T}^hoid 

Epidemics.     By  Dr.  E.  C.  Le^y        337 

ViabiUty  of  the  T}-phoid  Bacillus  Under  Natural 

Conditions.     By  Dr.  H.  D.  Pease 344 

Typhoid  Fever  in  United  States  Army  Camps  .    .  356 

Extract  from  President  Roosevelt's  Message    .    .  361 

}vledicine   in   Peace    and   War.     By  Dr.  L.   L. 

Seaman        362 

Economic  Statistics,     Pittsburg,  Pa 367 

T}'phoid  Fever  Literature.  368 

Tables  of  Typhoid  Fever  Statistics 372 


LIST   OF   ILLUSTRATIONS. 


PAGE 

Frontispiece.     Diagram    Illustrating    Transmission    of    Typhoid 

Fever iv 

Fig.     I.    Diagram  Showing  Temperature  of  the  Body  in  Typhoid 

Fever 4 

Fig.    2.    The  Typhoid  Bacillus 9 

Fig.    3.    Diagram  Illustrating  Longevity  of  the  Typhoid  Bacillus  in 

Water 48 

Fig.    4.    Diagram  Showing  Typhoid  Fever  in  St.  Louis loi 

Fig.  5.  Diagram  Showing  Age  Distribution  of  Typhoid  Fever  .  .  107 
Fig.    6.    Map  of  United  States  Showing  Distribution  of  Typhoid 

Fever         114 

Fig.    7.    Diagram  Illustrating  Seasonal  Distribution  of  Typhoid 

Fever         121 

Fig.    8,    Diagram  Illustrating  Seasonal  Distribution  of  Typhoid 

Fever  in  Cities .' 122 

Fig.    9.    Diagram  Illustrating  Seasonal  Distribution  of    Typhoid 

Fever  in  Albany,  N.  Y 123 

Fig.  ID.    Diagram  Showing  Relation  Between  Atmospheric  Tem- 
perature and  Typhoid  Fever 124 

Fig.  II.  Diagram  Showing  Decrease  in  Typhoid  Fever  since  1880,  130 
Fig.  12.    Diagram  Showing  Typhoid  Fever  Epidemic  in  Gelsen- 

kichen,  Germany 148 

Fig.  13.    Diagram    Showing  Typhoid  Fever  in  Lowell  and  Law- 
rence, Mass 153 

Fig.  14.    Diagram    Showing    Typhoid    Fever    in    Waterville    and 

Augusta,  Me 156 

Fig.  15.  Diagram  Showing  Typhoid  Fever  in  Pittsburg,  Pa.  ...  160 
Fig.  16.  Diagram  Showing  Typhoid  Fever  in  Chicago,  111.  ...  164 
Fig.  17.  Diagram  Showing  Typhoid  Fever  in  Cleveland,  Ohio  .  .  168 
Fig.  18.  Diagram  Showing  Typhoid  Fever  in  Cleveland,  Ohio  .  .  169 
Fig.  19.    Diagram  Showing  Typhoid  Fever  in  Burlington,  Vt.     .    .      1 72 

XX 


LIST   OF  ILLUSTRATIONS.  xxi 

PAGE 

Fig.  20.    Sketch  of  Brickyard  Spring,  Mount  Savage,  Md.     .    .    .  189 

Fig.  21.    Map  of  Winnipeg,  Manitoba 192 

Fig.  22.    Map  of  Winnipeg,  Manitoba 194 

Fig.  23.    Diagram  Showing  Types  of  Epidemics 210 

Fig.  24.    Diagram    Showing    Relation    Between    Water    Supplies 

and  Tj'phoid  Fever 229 

Fig.  25.    Diagram  Sho^\'ing  Relation  Between  Water  Supplies  and 

Typhoid  Fever 230 

Fig.  26.    Diagram   Showing  Typhoid   Fever  in    Frankfort-on-the- 

Main 231 

Fig.  27.    Diagram  Showing  Typhoid  Fever  in  Newark,  N.  J.  .    .    .  232 

Fig.  28.    Diagram  Showing  Typhoid  Fever  in  Jersey  City,  N.  J.    .  233 

Fig.  29.    Diagram  Showing  Typhoid  Fever  in  Lowell,  Mass.     .    .  234 

Fig.  30.    Diagram  Showing  Typhoid  Fever  in  Zurich,  Switzerland  .  236 

Fig.  31.    Diagram  Showing  Typhoid  Fever  in  Hamburg,  Germany  237 

Fig.  32.    Diagram  Showing  Typhoid  Fever  in  Lawrence,  Mass.  .    .  237 

Fig.  33.    Diagram  Showing  Typhoid  Fever  in  Albany,  N.  Y.  .    .    .  239 

Fig.  34.    Diagram  Showing  Typhoid  Fever  in  Binghampton,  N.  Y.  240 

Fig.  35.    Diagram  Showing  Typhoid  Fever  in  Watertown,  N.  Y.  .  241 

Fig.  36.    Diagram  Sho\^T[ng  Typhoid  Fever  in  Paterson,  N.  J.  .    .  243 

Fig.  37.    Diagram  Showing  Typhoid  Fever  in  Paris,  France   .    .    ,  244 

Fig.  38.    Diagram  Sho\\ang  Typhoid  Fever  in  St.  Louis,  Mo.    .    .  245 

Fig.  39.    Diagram  Shomng  Typhoid  Fever  in  Philadelphia,  Pa.     .  246 

Fig.  40.    Diagram  Showing  Typhoid  Fever  in  Youngstown,  Ohio .  249 

Fig.  41.    Diagram  Showing  Typhoid  Fever  in  Washington,  D.  C  250 

Fig.  42.    Diagram  Showing  Typhoid  Fever  in  Boston,  Mass.  ...  253 

Fig.  43.    Diagram  Showing  Typhoid  Fever  in  New  York  City  .    .  255 

Fig.  44.    Diagram  Showing  Typhoid  Fever  in  Brooklyn,  N.  Y.   .    .  257 

Fig.  45.    Diagram  Showing  Typhoid  Fever  in  Baltimore,  Md.    .    .  259 

Fig.  46.    Diagram  Sho\ving  Typhoid  Fever  in  Lorain,  Ohio    .    .    .  262 

Fig.  47.  Diagram  Showing  Typhoid  Fever  in  Hudson  Valley  .  .  .  264 
Fig.  48.    Diagram  Showing  Typhoid  Fever  in  Glasgow,  Liverpool 

and  London 269 

Fig.  49.    Common  Species  of  Flies " 297 

Fig.  50.    Diagram  Illustrating  Methods  of  Estimating  Population  .  304 


INTRODUCTORY   ESSAY 


TYPHOID    FEVER:    A  DISEASE   OF 
DEFECTIVE   CIVILIZATION. 

By   WILLIAM    T.   SEDGWICK 

TYPHOID  FE\^R  is  a  discovery  of  modern  civiliza- 
tion. WTien  Queen  Victoria  was  born,  in  1819, 
typhoid  fever  was  unknown.  \Mien  she  was  ten  years  old 
it  was  just  beginning  to  be  recognized  by  a  few  pioneers 
as  something  different  from  tophus  ("ship"  or  "jail"  or 
"camp"  or  "spotted")  fever,  with  which  it  had  hitherto 
been  everwhere  confounded.  TNTien  she  ascended  the 
throne,  in  1837,  it  was  still  generally  unrecognized,  even 
by  progressive  physicians.  In  a  report  on  the  Boston 
census  of  18-45,  published  in  1846  by  Lemuel  Shattuck, 
an  early  and  a  singularly  careful  student  of  vital  statistics, 
no  mention  is  made  of  t\'phoid  fever,  but  only  of  typhus; 
and  it  was  not  until  after  the  middle  of  the  nineteenth 
century  that  the  disease  became  widely  kno-mi  in  the 
United  ^States,  even  to  the  medical  profession.  Its  dis- 
covery, its  name,  its  natural  history,  and  the  general  recog- 
nition of  its  sanitary  and  economic  significance,  thus 
virtually  coincide  with  the  Victorian  era,  —  a  high  tide 
in  the  history  of  civilization.  It  is  still  of  frequent  occur- 
rence in  large  civilized  communities  as  widely  separated  as 


xxiv      A  DISEASE   OF  DEFECTIVE  CIVILIZATION. 

Paris  and  Pittsburg,  as  well  as  in  a  host  of  smaller  but  no 
less  civilized  places.  It  caused  in  1906,  for  example, 
253  deaths  in  London,  639  in  New  York,  370  in  Chicago, 
122  in  Boston,  161  in  Washington. 

But  while  it  is  true  both  historically  and  as  a  fact  of 
to-day,  that  typhoid  fever  is  a  disease  of  civilization,  it  ought 
to  be  clearly  understood  that  it  is  only  a  disease  of  defective 
civilization,  for  it  has  gradually  become  notorious  that  the 
widespread  or  frequent  occurrence  of  typhoid  fever  in  any 
community  must  be  due,  somehow,  to  defective  sanita- 
tion; and  defective  sanitation  means  defective  civilization. 
It  is  also  now  generally  believed  that  this  disease,  though 
specifically  unknown,  was  really  much  more  common  and 
a  much  greater  scourge  of  mankind  before  the  Victorian 
era  than  it  is  to-day. 

The  broad  outlines  of  the  natural  history  of  typhoid 
fever  have  now  been  known  for  more  than  three  quarters 
of  a  century.  The  particular  parasite  or  microbe  which 
causes  it  has  been  well  known  since  1884,  that  is  to  say,  for 
almost  a  quarter  of  a  century,  and  the  principal  habits, 
habitats,  and  means  and  modes  of  transmission  of  the 
microbe,  nearly  as  long.  The  experience  of  various  com- 
munities, some  large  and  some  small,  in  first  extermina- 
ting and  then  for  the  most  part  keeping  off  the  disease,  has 
demonstrated  the  possibility  of  its  control.  It  is  therefore 
impossible  to  avoid  the  conclusion  that  communities  in 
which  typhoid  fever  abounds  are  either  ignorant  or  care- 


INTRODUCTORY  ESSAY.  xxv 

less;  and  ignorance  and  carelessness  are  the  ear  marks  of 
a  defective  civilization. 

And  what  is  here  true  of  cities,  towns  and  other  large 
communities,  is  equally  true  of  the  smallest,  which  is  the 
family.  The  appearance  of  typhoid  fever  in  any  family, 
even  in  one  member  of  it,  is  likewise  evidence  of  defective 
sanitation,  although,  unhappily,  the  insanitation  which 
thus  shows  its  dangerous  effects  may  have  existed,  not  in 
the  household  or  the  family  affected,  nor  even  in  the  city, 
town  or  village  of  which  it  is  a  part,  but  on  some  remote 
and  lonely  farm,  or  some  distant  fruit  ranch,  or  at  the 
bottom  of  some  quiet  harbor  planted  with  oysters  but 
polluted  with  sewage. 

There  is  a  fascination,  a  dramatic  interest,  in  working 
out,  even  in  imagination,  the  dark  and  devious  paths  and 
bypaths  along  which  the  microscopic  parasites  that  afflict 
the  human  race  travel  to  their  appointed  victims.  Only 
the  epidemiologist  realizes  the  full  meaning  of  the  phrase, 
"the  pestilence  that  walketh  in  darkness."  All  the  skill 
of  an  expert  detective  is  often  required,  —  and  often  fails, 
—  to  discover  the  exact  manner  and  the  exact  route  by 
which  typhoid  fever  was  actually  conveyed  from  one 
person  to  another;  for  while  in  some  cases  the  way  is  clear 
and  short,  in  others  it  is  obscure  and  long.  Those  who 
read  Mr.  Whipple's  account  of  various  epidemics,  notably 
that  at  Plymouth,  Penn.,  in  1885,  will  perhaps  realize  in 
some  measure  what  is  meant  by  these  statements. 


xxvi     A  DISEASE  OF  DEFECTIVE  CIVILIZATION. 

It  will  be  clear  from  what  has  already  been  said  that 
typhoid  fever  is  to-day  universally  regarded  as  a  parasitic 
disease.  A  case  of  typhoid  fever  is  probably  as  truly  a  case 
of  parasitism  as  is  a  case  of  the  itch,  or  of  trichinosis,  or 
of  tape- worm;  and  the  phenomena  of  the  disease,  or  the 
sickness  of  the  patient,  are  as  truly  the  reaction  of  the 
organism  to  the  attack  of  the  parasite  as  are  the  galls  of 
oak  trees  to  the  poison  introduced  by  the  gall  fly,  or  the 
redness,  pain  and  swelling  which  follow  a  mosquito  bite  to 
an  attack  by  a  mosquito,  — that  most  familiar  of  parasites. 
In  other  words  and  from  one  point  of  view  there  is  no  longer 
any  mystery  about  a  case  of  typhoid  fever.  Each  and 
every  case  comes  somehow  from  some  previous  case. 
Whatever  mystery  there  may  be  about  it  concerns  the 
mode  of  transmission,  —  not  the  character  of  the  causative 
agent. 

And  yet,  in  common  with  other  contagious  and  infectious 
diseases  typhoid  fever  was  for  a  long  time  thought  to 
arise  spontaneously.     Trousseau,  for  example,  said 

"  La  spontaneite  est  done  un  fait  incontestable  dans  le  developpment 
des  maladies,  mgme  les  plus  contagieuses." 

Murchison  went  further  and  in  his  popular  "pythogenic" 
theory  assumed  that  typhoid  fever 

"  may  be  generated  independently  of  a  previous  case  by  fermentation  of 
fecal  and  perhaps  other  forms  of  organic  matter  ...  it  is  developed 
by  the  decomposition  of  the  excreta  after  their  discharge." 


INTRODUCTORY  ESSAY.  xxvii 

To  this  last  Dr.  William  Budd,  of  whom  and  of  whose 

work  more  will  be  said  beyond,  pungently  replied, 

"  To  conclude,  on  the  evidence  usually  assigned  for  such  a  belief,  that  a 
poison,  of  whose  growth  this  is  the  history,  is  bred  in  every  cesspool  or 
ditch  in  which  there  may  chance  to  be  a  heap  of  seething  rottenness,  is 
precisely  on  a  par  with  the  philosophy  which  led  the  ancients  to  believe 
that  mushrooms  are  bred  of  cow-dung,  alligators  of  the  mud  of  the  Nile, 
and  that  bees,  as  Virgil  sang,  may  be  engendered  in  the  entrails  of  a 
putrid  ox." 

The  rise  of  the  germ  theory  of  zymotic  diseases  and  the 
discovery  of  specific  parasites  for  the  principal  infec- 
tions laid  to  rest  the  time-worn  theory  of  the  spontane- 
ous generation  of  the  poisons  of  the  infectious  diseases, 
and  to-day  the  Eberth-Koch-Gaffky  bacillus  is  everywhere 
regarded  as  the  true  parasite  and  sole  exciting  cause  of 
typhoid  fever. 

Contrary  to  the  views  of  some,  the  parasite  which  pro- 
duces in  its  host  what  we  call  typhoid  fever  does  not  appear 
to  be  widely  distributed  in  nature,  if  indeed  it  thrives  at 
all  "wild"  outside  the  bodies  of  its  hosts.  The  best  proof 
of  this  is  the  fact  that  typhoid  fever  during  an  epidemic 
attacks  very  readily  persons  in  poor  health,  the  over- 
worked, those  who  are  run  down  and  the  like;  and  yet 
persons  of  this  sort  may  and  do  abound  in  any  given 
community  for  years  without  suffering  from  typhoid  fever, 
while  on  the  arrival  of  some  traceable  infection  of  food 
or  drink  by  typhoid  parasites  they  speedily  take  and 
suffer  from  the  disease. 


xxviii   A    DISEASE  OF  DEFECTIVE  CIVILIZATION. 

The  parasite  of  typhoid  fever  also  seems  to  be  com- 
paratively hardy.  This  at  least  is  indicated  by  its  frequent 
survival  in  water  and  milk,  and  its  occasional  occurrence 
in  oysters,  ice,  air,  sewage  and  elsewhere  outside  of  the 
human  body,  which  must  probably  be  regarded  as  its 
most  favorable  habitat.  For  this  reason  it  offers  special 
advantages  as  a  sanitary  test  or  "sanitary  index"  of  the 
general  purity  of  food  and  drink  as  regards  infectious 
microbes;  the  argument  being  that  if  this  comparatively 
hardy  parasite  is  absent,  other  infectious  micro-organisms 
are  probably  absent  also.  If  this  one  is  present,  it  obviously 
matters  comparatively  little  about  others,  since  typhoid 
fever  alone  is  sufficiently  alarming.  It  is,  of  course,  easy 
to  show  the  inadequacy  of  this  or  any  other  single  "  sanitary 
index,"  since,  for  example,  a  milk  free  from  typhoid  has 
been  known  to  cause  hundreds  of  cases  of  scarlet  fever. 
And  yet  it  is  roughly  true  that  for  any  community  which 
has  constantly,  year  after  year,  a  good  record  in  respect 
to  typhoid  fever,  the  presumption  is  that  sanitary  con- 
ditions are  at  least  fair.  Strictly  speaking,  however,  no 
such  conclusion  is  justified,  unless  for  the  water  supply, 
which,  as  far  as  is  now  known,  is  not,  like  milk,  a  ready 
vehicle  of  other  infections. 

One  of  the  most  striking  and  important  of  recent  ad- 
vances in  our  knowledge  of  the  typhoid  parasite  is  the 
fact  that  it  appears  to  linger  in  the  body  of  its  recovered 
host,  sometimes  for  months   and  even  years,  passing  off 


INTRODUCTORY  ESSAY.  xxix 

from  time  to  time  in  the  excreta  and  infecting,  or  tending 
to  infect,  fresh  victims.  Every  host  is,  of  course,  strictly 
speaking,  during  his  ilhiess  a  "typhoid  carrier,"  but  by 
common  consent  this  term  is  now  reserved  for  survivors 
from  the  disease  and  others  who  in  complete  health  con- 
tinue unwittingly  to  be  a  breeding  ground  for  the  bacilli 
and  to  discharge  the  typhoid  parasites  into  their  environ- 
ment. There  is  nothing  unlikely  or  unprecedented  about 
all  this,  for  we  already  have  in  fact  though  not  in  name, 
diphtheria  "carriers,"  i.e.,  persons  who  have,  or  even 
have  not,  had  diphtheria,  and  yet  show  its  germs  in  cultures 
taken  from  the  throat.  If  the  time  ever  comes,  as  seems 
likely  will  be  the  case,  when  a  determination  of  the  presence 
or  absence  of  the  typhoid  parasite  in  the  body  can  be 
made  as  easily,  and  as  accurately,  as  is  now  done  for 
diphtheria,  a  great  step  forward  will  have  been  taken. 

One  of  the  first  questions  that  arises  when  a  case  of 
typhoid  fever  appears  in  a  family  is  whether  or  not  the 
disease  is  contagious,  and  too  often  the  family  physician 
replies,  "No:  it  is  not  contagious:  it  is  only  infectious." 
But  in  point  of  fact  this  question  is  as  old  as  our  knowledge 
of  the  fever  itself,  and  has  probably  been  the  subject  of 
more  controversy  than  any  other  problem  relating  to  the 
disease.  When,  for  example,  in  1829  typhoid  was  first 
clearly  differentiated  by  Louis  from  typhus  fever  through 
the  fact  that  the  former  alone  is  characterized  by  localized 
ulcers    in    the    small    intestine,    that    investigator   noted 


XXX      A  DISEASE   OF  DEFECTIVE  CIVILIZATION. 

that  typhoid  was  contagious,  though  less  so  than  typhus 
fever.  Other  workers  alleged  that  one  of  the  most  dis- 
tinctive differences  between  the  two  was  that  typhus  was, 
and  typhoid  was  not,  contagious.  The  two  diseases  were 
so  much  alike  that  many  denied  that  they  really  differed, 
and  apparently  the  desire  to  prove  them  different  led  to 
an  exaggeration  of  the  difference  in  respect  to  their  con- 
tagiousness. However  this  may  be,  the  truth  is  that  the 
contagiousness  of  typhoid  has  been  almost  always  under- 
estimated, and  this  in  spite  of  the  fact  that  Louis,  who 
established  the  specific  character  of  typhoid  fever,  Chomel, 
wh©  gave  to  it  its  name,  Bretonneau  and  Trousseau,  in 
France,  and  Murchison  and  Sir  William  Jenner,  in  Eng- 
land, all  asserted  clearly  and  positively  that  it  is  a  conta- 
gious disease.    Chomel  for  example,  observes  (in  1834)  that 

"  there  is  a  great  difference  of  opinion  among  medical  men,  —  the  majority 
in  France  denying  every  kind  of  contagion  in  this  disease,"  — 

their    principal   reason    being,  apparently,  that  of  those 

surrounding   the  patient    only  a    few  take    the    disease. 

Chomel  concludes  that  though  plainly  contagious  it  must 

be  less  contagious  than  many  other  diseases. 

Sir  William  Jenner,  about  1850,  after  a  careful  study  of 

typhus  and  typhoid  fevers  wrote :  — 

"  If  typhoid  fever  be  contagious  it  is  infinitely  less  so  than  typhus.  My 
experience  leads  me  to  regard  it  as  contagious." 

Dr.  Murchison,  in  1858,  gave  it  as  his  opinion  that 

"  typhus  fever  is  eminently  contagious.  Typhoid  fever  is  also  contagious 
but  in  a  more  limited  degree  and  possibly  through  a  different  medium." 


INTRODUCTORY  ESSAY.  ..  xxxi 

Four  years  later  he  affirmed: 

"  It  may  be  communicated  by  the  sick  to  persons  in  health,  but  even  then 
the  poison  is  not  like  that  of  smallpox  given  off  from  the  body  in  a  viru- 
lent form,  but  is  developed  by  the  decomposition  of  the  excreta  after  their 
discharge.  Consequently  an  outbreak  .  .  .  implies  poisoning  of  air, 
drinking  water  or  other  ingesta,  with  decomposing  excrement." 

Thus  matters  stood  when,  in   1873,  the  splendid  and 

convincing    work    of    Dr.    Willliam    Budd,    an    English 

physician,  appeared,  and  proved  beyond  the  shadow  of  a 

doubt  that  typhoid  fever  is  a  decidedly  contagious  disease. 

No    student   of   typhoid   fever   should   fail   to    read   this 

remarkable  volume  and  to  make  thereby  the  acquaintance 

of  a  master  of  keen   and  minute  analysis  and  vigorous 

inductive   reasoning.     Tyndall   has  referred  to   Budd   as 

"  a  man  of  genius  withdrawn  from  the  stimulus  of  the  Metropolis  and 
working  alone  at  a  time  when  the  whole  medical  profession  in  England 
entertained  views  opposed  to  his." 

Budd's   position   was  so   strong  that   Professor  Tyndall, 

whose  ability  to  weigh  evidence  will  hardly  be  questioned, 

was  fully  convinced  and  in   1874  wrote  a  strong  letter 

to  the  London  Times,  saying, 

"  How  could  a  disease  whose  characteristics  are  so  severely  demonstrable 
have  ever  been  imagined  to  be  non-contagious  ?  How  could  such  a  doc- 
trine be  followed  out,  as  it  has  been,  to  the  destruction  of  human  life .-'" 

Dr.  W.  H.  Corfield  in  1874  went  further,  declared  typhoid 

to  be  "virulently"  contagious,  and  explained  the  differences 

of  the  contagionists  and  the  anti-contagionists  as  follows :  — 

"  That  it  is  contagious,  and  most  virulently  so,  I  have  not  the  slightest 
doubt;  but  I  quite  imderstand  what  those  mean  who  say  it  is  not;  they 


xxxii      A  DISEASE   OF   DEFECTIVE   CIVILIZATION. 

mean  that  if  you  attend  upon  a  patient  suffering  from  typhoid  fever  you  are 
not  Hkely  to  get  it,  while  if  you  attend  on  one  suffering  from  typhus  or 
scarlet  fever  you  are  very  likely  to  do  so,  unless  you  have  had  the  disease 
before ;  they  do  not  consider  that  this  fact  is  not  due  to  a  difference  in  the 
contagious  nature  of  the  disease  but  to  a  difference  in  the  form  in  which 
the  poison  is  excreted  from  the  patient,  most  of  it  being  in  the  one  case 
given  out  into  the  air  which  the  attendants  breathe,  while  in  the  other  most 
of  it  is  swamped  in  a  mass  of  liquid  which  is  removed  as  soon  as  possible. 
Those  accustomed  to  smallpox,  scarlet  fever  and  the  like,  of  course, 
said  that  typhoid  fever  was  not  contagious,  when  it  was  first  brought  to 
their  notice,  and  there  is  no  doubt  that  it  is,  under  ordinary  circumstances, 
very  slightly  so  in  their  limited  sense  of  the  word ;  but  that  is  not  what  is 
meant  by  those  who  now  deny  that,  except  under  certain  circumstances, 
it  is  not  communicable  from  one  person  to  another." 

I  have  dwelt  upon  this  matter  at  some  length  because 
the  true  contagiousness  of  typhoid  fever  is,  even  to-day, 
not  recognized  or  taught  as  fully  as  it  should  be.  No 
one  pretends  that  typhoid  fever  is  as  contagious  as  small- 
pox or  scarlet  fever,  or  perhaps  even  as  diphtheria. 
Doctor  Corfield  in  the  quotation  just  given  has  well 
stated  the  reasons  why;  reasons  which,  though  formulated 
before  the  germ  theory  had  been  proven  or  the  microbic 
parasite  of  typhoid  fever  discovered,  are  no  less  sound 
to-day.  With  the  rise  of  that  theory  and  the  discovery  of 
the  parasites  of  the  principal  infections;  with  the  brilliant 
achievements  of  epidemiology  and  the  novel  and  startling 
discoveries  of  the  role  played  by  polluted  water,  polluted 
milk  and  other  food  materials,  such  as  shellfish;  with  the 
astounding  revelations  of  the  damage  done  by  insects  as  car- 
riers of  malaria  and  yellow  fever  and  plague ;  the  humbler, 
more  insidious,  and  less  spectacular  part  played  by  dirty 


INTRODUCTORY  ESSAY.  xxxiii 

hands,  soiled  linen,  dirty  bedding,  dirty  towels,  dirty  dishes, 
dirty  forks  and  knives  and  spoons,  dirty  toys  or  playthings, 
dirty  pencils,  dirty  candy  or  similar  objects,  handled  or 
mouthed  or  kissed  or  sucked  or  spit  upon,  by  persons 
having  typhoid  fever,  have  attracted  but  small  attention. 
Yet  it  is  to  direct  infection  of  this  sort  (which  is  what  we 
mean  by  "contagion")  that  We  probably  have  to  look 
for  a  large  part  of  that  residual  typhoid  which  still  clings 
to  many  communities  even  after  the  water  supply  has 
been  purified,  the  milk  supply  cared  for  and  the  various 
other  public  supplies  controlled.  There  may  have  been 
a  time  previous  to  1873  when  a  well  informed  physician  in 
order  to  calm  the  fears  of  a  family  having  a  case  of  typhoid 
fever  could  have  said  conscientiously,"  You  need  have  no 
apprehensions  for  the  rest  of  the  family;  typhoid  is  not 
contagious,  it  is  only  infectious."  But  since  Budd's 
great  work,  no  scientific  man,  at  least,  would  have  dared  to 
say  as  much.  Those  who  depend  on  any  such  statement 
are  living  in  a  fool's  paradise,  for  to-day  it  is  a  well  known 
fact  that  even  trained  nurses  in  attendance  on  hospital 
cases  where  safeguards  abound  are  often  unable  to  escape 
an  infection  which  is  practically  contagion;  and  this  in 
spite  of  abundant  knowledge,  frequent  warnings,  and  some 
painstaking.  They  may  not  have  caught  the  parasites  by 
touching  their  patients.  They  may  have  touched  the 
patient's  contaminated  clothing,  or  bedding,  or  food,  or 
utensils,  or  excreta.     But  between  an  infection  so  direct 


xxxiv  A  DISEASE   OF  DEFECTIVE  CIVILIZATION. 

and  so  short-circuited  and  that  which  comes  from  actual 
contact  with  the  person  of  the  patient,  there  is  no  essen- 
tial or  important  difference ;  and  it  is  a  satisfaction  to  one 
who,  following  William  Budd,  for  years,  and  sometimes  in 
the  face  of  adverse  criticism,  has  taught  that  typhoid 
fever  is  a  contagious  disease,  to  find  that  fact  now  more 
generally  admitted,  and  even  made  popular  among  physi- 
cians by  so  good  an  authority  as  Conradi. 

"  Twenty  years  ago  I  received  letters  describing  to  me  the  grief  and 
ruin  introduced  into  families  through  the  notion,  then  prevalent,  that 
typhoid  fever  is  non-contagious.  When  Dr.  William  Budd  published  his 
researches  on  this  subject,  showing  by  facts  and  reasonings,  as  cogent  as  it 
was  in  the  power  of  science  to  supply,  the  infectiousness  of  the  fever, 
certain  writers  discerned  in  that  important  work  a  proof  of  the  decadence 
of  Budd's  intellect  and  gave  the  public  the  benefit  of  their  conclusions." 
(Professor  Tyndall,  New  Fragments,  p.  428.) 

One  very  disagreeable  fact  about  typhoid  fever  is  that 
it  is  intimately  associated  with  human  excrements. 
Diphtheria  parasites  are  probably  cast  off  chiefly  in  the 
sputum.  Bacillus  tuberculosis,  according  to  some  recent 
ideas,  is  given  off  freely  by  tuberculous  cows  in  their  milk, 
their  sputum  and  their  excrement.  But  since  the  lower 
animals  do  not  have  typhoid  fever,  man  is  the  only  source 
of  the  peculiar  parasites  of  this  disease,  and  though  the 
germs  may  occur  in  the  spit  and  sweat  it  is  believed  that 
they  occur  most  often  and  most  abundantly  in  the  urine  and 
feces  of  typhoid  fever  patients.  Hence  it  follows  that  if 
water,  milk,  oysters,  etc.,  convey  these  germs,  they  have 
probably  been  contaminated  by  human  excrement.     Such 


INTRODUCTORY  ESSAY.  ^xxv 

contamination  often  arises  by  the  way  of  sewage  pollution 
of  foods  and  drinking  water  supplies.  But  if  the  recent 
discoveries  relating  to  typhoid  "  carriers "  are  correct  and 
logically  interpreted,  they  indicate  a  more  direct,  more 
personal  and  more  disgusting  contamination  of  food  and 
drink  by  servants  and  others  of  unclean  habits,  and  compel 
us  to  assume  an  easy  transfer  of  filth  from  one  person  to 
another  through  contact  of  excrements  with  food  or  drink. 

To  overcome  this  disgusting  condition,  which  is  far  too 
common,  nothing  will  suffice  except  education  in  personal 
hygiene  or,  what  ought  to  include  this,  careful  home  train- 
ing. Sanitation  can  effect  the  purification  of  public 
water  supplies,  but  it  cannot  either  induce  or  compel 
waitresses  to  wash  their  hands  before  passing  from  the 
water  closet  to  the  china  closet.  This,  only  education  or 
training  can  do,  and  until  they  have  done  it,  unclean  ser- 
vants will  continue  to  be  what  they  are  to-day,  a  serious 
menace  to  personal  and  family,  as  well  as  public,  health. 

The  statement  is  often  made  that  "  for  every  case    / 

typhoid  fever  some  one  ought  to  be  hanged."     j.    •    „ 

striking  saying  and  worth  remembering,  because-.       .    .i 

responsibility  for  this  disease  where  it  be!  ^  i„ 

^  "^  -ongs,  namely, 

upon  mankind,  and  not  upon  fate  or  the  g^  i  -p  .  „j,iggg 
hanging  is  to  be  introduced  as  a  penalty  ^^^  j^^^^^^ce  and 
neglect,  it  is  not  often  true.  What  ;  ^^^^  j^  ^^^^  ^^^^y 
case  of  typhoid  fever  comes  from  so^^^^^^^,^  ignorance  or 
neglect.     And  here  also  the  reme^.^^  ^^^  education  and 


xxxvi  A  DISEASE   OF  DEFECTIVE   CIVILIZATION. 

training,  with  penalties  only  for  criminal  negligence.  We 
might  more  truly  say  that  for  every  case  of  typhoid  fever 
some  one  ought  to  be  educated. 

And  just  here  Mr.  Whipple's  work  is  certain  to  do  great 
good.  Itself  a  remarkable  witness  to  the  variety  of  inter- 
ests concerned  with  or  affected  by  typhoid  fever,  it  is 
important  also  as  a  demonstration  of  the  intimate  relations 
already  established  and  to-day  rapidly  increasing  between 
sanitary  biology,  preventive  medicine  and  sanitary  engi- 
neering. 

"  For  we  are  not  dealing  here  with  questions  of  which  the  interest  is 
absti-act  only  .  .  .  but  with  a  matter  which,  take  the  world  over,  for 
every  year  that  passes  is  life  or  death  to  myriads  of  men.   .   .  . 

"  And  let  no  one  suppose  that  this  is  a  matter  in  which  he  has  no 
personal  interest.  This  disease  not  seldom  attacks  the  rich,  though  it 
thrives  most  among  the  poor.  But  by  reason  of  our  common  humanity 
we  are  all,  whether  rich  or  poor,  more  nearly  related  here  than  we  are 
apt  to  think.  The  members  of  the  great  human  family  are  bound 
together  by  a  thousand  secret  ties  of  whose  existence  the  world  in  gen- 
eral little  dreams.  And  he  that  was  never  yet  connected  with  his  poorer 
neighbour  by  deeds  of  charity  or  love,  may  one  day  find,  when  it  is  too 
late,  that  he  is  connected  with  him  by  a  bond  which  may  bring  them 
both  to  a  common  grave."  (William  Budd,  Typhoid  Fever.  London, 
1873.) 


\ 


\ 


TYPHOID    FEVER. 


CHAPTER  I. 
TYPHOID   FEVER. 

Typhoid  fever,  or  enteric  fever,  is  an  intestinal 
disease,  caused  by  a  microbe  kno^^^l  as  "Bacillus  ty- 
phosus," or  more  commonly  as  "B.  typhi,"  or  "the 
typhoid  bacillus. "  Through  the  multiplication  of  this 
germ  within  the  body,  with  the  consequent  production 
of  a  poisonous  substance,  which,  for  want  of  a  better 
understanding,  may  be  termed  typhotoxin,  morbid  con- 
ditions are  produced  in  various  parts  which  give  rise 
to  the  characteristic  symptoms  of  the  disease.  Ulcer- 
ations of  the  intestines  and  enlargements  of  the  mesen- 
teric glands  and  spleen  are  the  most  pronounced  of 
these  lesions;  but  being  transported  by  the  blood  the 
bacilli  often  invade  other  organs  of  the  body,  —  the 
kidneys,  the  liver,  the  lungs,  the  bone-marrow. 

Symptoms.  The  symptoms  of  a  typical  case  of 
typhoid  fever  are  well  defined,  but  so  many  exceptional 
or  atypical  cases  occur,  and  the  early  symptoms  are  so 
often  indistinct,  that  errors  in  diagnosis  are  not  uncom- 
mon. The  most  characteristic  symptoms  are  a  gradually 
increasing  and  regularly  fluctuating  temperature,  general 


2  TYPHOID    FEVER. 

prostration,  diarrhea  (or  perhaps  constipation),  frontal 
headache,  nose-bleed,  dry  cough,  enlarged  spleen,  rose- 
rash  over  the  abdomen  and  sometimes  elsewhere,  gas- 
eous distension  of  the  intestines,  emaciation,  and,  in 
severe  cases,  intestinal  hemorrhages,  and  delirium. 
These  symptoms  cover  an  average  period  of  four  or  five 
weeks,  but  they  may  be  preceded  by  a  week  or  two 
of  general  malaise,  and  are  followed  by  a  rather  long 
period  of  convalescence,  during  which  relapses  are  not 
infrequent.  Fatal  cases  usually  terminate  during  the 
fourth  or  fifth  week  of  the  disease,  or  after  a  relapse. 

Diagnosis  of  typhoid  fever  cannot  often  be  made 
within  four  or  five  days  after  the  onset,  as  many  of  the 
symptoms  may  be  wanting  in  any  particular  case.  The 
presence  of  the  rose-rash  or  a  positive  bacteriological 
test  of  the  blood  are  usually  necessary  to  make  the 
diagnosis  certain. 

A  Typical  Case.  A  typical  case  of  typhoid  fever  is 
likely  to  give  the  following  medical  history: 

Between  the  time  when  the  typhoid  bacillus  enters  the 
body  and  the  time  when  the  patient  realizes  that  he  is 
seriously  ill,  there  is  a  so-called  incubation  period,  or 
prodromal  period,  which  usually  lasts  about  two  weeks, 
but  which  may  vary  from  one  week  to  three.  During 
this  time  the  health  may  be  apparently  unaffected,  but 
more  often  the  patient  feels  played  out,  loses  appetite, 
and  "aches  all  over."  The  true  onset  is  generally 
accompanied  by  symptoms  which  compel  the  patient 
to  take  his  bed  and  call  his  physician.  There  may  be 
shivering,  or  perhaps  a  chill,  headache,  a  coated  tongue; 
perhaps  nose-bleed  or  a  bronchial  cough;  fever,   rest- 


TYPHOID    FEVER.  3 

lessness  and  insomnia,  muscular  weariness,  thirst,  nausea; 
there  may  be  either  diarrhea  or  constipation.  These 
symptoms  continue  during  the  first  week,  the  tempera- 
ture gradually  rising  to  103  or  104  degrees  at  night, 
with  a  corresponding  increase  in  the  morning  tempera- 
ture, which  is  lower  than  at  night,  the  pulse  also  show- 
ing a  slight  elevation. 

During  the  second  week  most  of  the  symptoms  become 
worse,  but  headache  and  nausea  disappear.  The 
temperature  rises  to  104  or  105  degrees,  w^ith  morning 
remissions  of  one  or  two  degrees;  the  pulse  rises  to  100 
or  no  and  becomes  weaker.  Prostration  and  apathy 
become  great,  the  voice  feeble,  the  tongue  dry  and  brown. 
The  bowel  discharges  are  frequent  and  loose,  pale 
yellowish  brown  in  color,  and  more  or  less  lumpy.  About 
the  eighth  or  tenth  day  rose-spots  about  one-eighth  of 
an  inch  in  diameter  appear  on  the  abdomen,  coming 
and  going  in  successive  crops,  lasting  only  a  few  days 
each,  and  disappearing  altogether  during  the  third 
week.  Nervous  tremors  become  conspicuous,  and  there 
may  be  some  delirium. 

During  the  third  week  the  night  temperatures  continue 
high,  but  the  morning  remissions  may  be  somewhat 
lower.  The  patient  becomes  emaciated,  semi-conscious, 
and  perhaps  delirious.  The  stools  may  become  tinged 
with  blood,  the  urine  lessened  in  amount.  During  this 
week,  pulmonary  complications  are  most  likely  to  develop, 
—  sometimes  pneumonia. 

During  the  fourth  week  night  temperatures  slowly 
fall  to  102  or  loi  degrees,  while  the  morning  tempera- 
tures begin  to   approach  normal,   even  becoming  sub- 


TYPHOID    FEVER. 


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TYPHOID    FEVER.  5 

normal  in  some  instances.  With  lower  temperatures  all 
the  symptoms  tend  to  improve,  the  pulse  grows  stronger, 
the  mind  becomes  clear,  the  tongue  becomes  moist, 
and  the  patient  begins  to  desire  food. 

The  fever  sometimes  persists  for  a  few  weeks  longer, 
but  usually  the  fifth  week  begins  the  period  of  convales- 
cence, which  may  last  anywhere  from  two  or  three  weeks 
to  as  many  months,  and  if  no  complication  sets  in  the 
patient  recovers.  Indiscretions  in  eating,  in  exercise, 
or  exposure,  however,  may  cause  a  dangerous  relapse, 
during  which  there  is  a  repetition  of  the  original  symp- 
toms. The  second  attack  is  seldom  as  severe  as  the 
original  one;  but,  on  the  other  hand,  the  reserve  strength 
of  the  patient  is  correspondingly  less,  so  that  relapses 
are  always  to  be  dreaded. 

Treatment.  Good  nursing,  proper  diet  and  hygiene, 
and  the  free  use  of  the  cold  bath,  effect  a  cure  in  from 
90  to  95  per  cent  of  the  cases.  Medicinal  treatment 
aimed  directly  at  the  disease  counts  for  little,  and  thus 
far  no  antitoxin  has  been  found  to  counteract  the  effect 
of  the  bacterial  poison  similar  to  those  which  have  ac- 
complished such  marvelous  results  with  diphtheria  and 
tetanus.  Medical  treatment  is  devoted  rather  to  assist- 
ing the  various  organs  of  the  body  to  perform  their 
normal  functions  under  the  unusual  conditions,  to 
prevent  any  overstrain  on  any  weak  organs,  and  to  ward 
off,  as  well  as  possible,  any  unusual  complications. 
Nature  practically  cures  the  disease,  and  both  nursing 
and  medical  treatment  are  adjusted  so  as  to  give  Nature 
as  free  a  hand  as  possible  in  doing  so. 

Complications.     It  is   said  that  not  over  a   third  of 


6  TYPHOID    FEVER. 

the  deaths  from  typhoid  fever  are  due  directly  to  the 
effects  of  the  disease,  i.e.,  to  the  effects  of  the  typho- 
toxin.  Two-thirds  of  the  deaths  are  due  to  the  numerous 
compHcations,  among  which  pneumonia  and  tuberculosis 
are  prominent.  This  is  a  most  important  matter  to 
sanitarians  in  connection  with  death  certificates. 

"  Walking  "  Cases.  Some  cases  are  so  mild  that  they 
are  not  recognized  as  typhoid  fever  at  all.  The  patient, 
though  not  feeling  well,  remains  up  and  goes  about 
his  usual  pursuits.  Ultimately  he  may  recover  without 
knowing  he  has  had  the  disease,  or  he  may  suddenly 
become  seriously  ill.  Such  cases  are  called  "walking" 
cases,  and  for  obvious  reasons  they  are  especially  dan- 
gerous to  the  public.  Children,  particularly,  are  liable 
to  have  mild  attacks  of  typhoid  fever  which  go  unrec- 
ognized. It  seems  probable  also  that  a  person  may 
harbor  the  typhoid  bacillus  without  having  the  disease 
at  all.  Reference  to  the  so-called  "typhoid  carriers" 
is  given  on  a  later  page. 

Details  of  the  various  symptoms,  methods  of  treat- 
ment, studies  of  exceptional  cases,  complications  and 
after-effects,  are  important  matters  to  be  considered 
from  the  standpoint  of  the  patient  and  of  the  physician, 
but  less  so  from  that  of  the  sanitarian,  whose  interest 
lies  chiefly  in  those  things  which  concern  the  transmis- 
sion of  the  disease  or  which  affect  the  vital  statistics. 
So  far  as  the  disease  itself  is  concerned  the  most  impor- 
tant facts  for  him  are  those  which  throw  light  upon  the 
probable  date  of  the  infection  and  the  duration  of  any 
particular  case. 

Allied  Diseases.     There  are  several  intestinal  diseases 


TYPHOID    FEVER.  7 

closely  allied  to  typhoid  fever,  milder  in  character,  and 
not  as  definite,  either  in  their  pathology  or  bacteriology. 
That  which  is  most  like  the  typical  disease  is  knowoi 
as  parat}'phoid  fever.  This  term  has  not  vet  come 
into  common  use  among  practicing  physicians,  and  its 
systematic  position  is  not  \vell  established.  Many  bac- 
teriologists, however,  recognize  the  paratyphoid  bacillus 
as  distinct  from  bacillus  typhosus.  Then  there  is  a 
certain  t}'pe  of  dysentery  caused  by  the  Shiga  bacillus, 
—  in  fact  there  are  several  varieties  of  this  bacillus. 

These  dysenteries  are  sometimes  termed  '"'infantile 
cholera,"  " "winter  cholera,"  "summer  complaint,"  etc. 
Then  there  is,  of  course,  the  true  Asiatic  cholera,  which 
is  similar  to  typhoid  fever  in  its  modes  of  transmission. 

If  this  were  a  medical  book  it  would  be  appropriate 
to  discuss  these  allied  diseases,  but  as  the  factors  that 
influence  their  transmission  are  very  largely  the  same 
as  in  the  case  of  typhoid  fever,  and  as  the  bacteriology 
of  the  diarrheal  diseases  is  in  an  uncertain  and  con- 
troversial state,  no  further  reference  to  them  will  be 
made. 


CHAPTER    11. 
BACTERIOLOGY   OF   TYPHOID    FEVER. 

The  typhoid  bacillus  was  discovered  by  Eberth  in 
1880,  and  soon  afterward  was  isolated  and  studied  in 
pure  culture  by  Koch,  Gaffky,  and  others.  It  has  been 
known  to  science  only  a  quarter  of  a  century,  yet  in  that 
time  it  has  been  the  subject  of  research  by  hundreds  of 
investigators  working  in  many  lands.  A  mere  list  of 
the  titles  of  the  papers  which  have  been  written  about 
typhoid  fever  would  fill  a  volume  of  considerable  size. 
Yet  with  all  this  study  we  know  but  little  about  the  inner 
structure  of  the  organism,  little  about  its  physiology, 
and  little  about  the  conditions  which  affect  its  behavior 
inside,  or  its  longevity  outside  the  human  body.  The 
little  that  we  do  know,  however,  is  of  great  practical 
importance,  and,  considering  the  difficulties  involved,  is 
most  creditable  to  the  new  science  of  bacteriology. 

The  Typhoid  Bacillus.  '  The  typhoid  bacillus  is  a 
minute  vegetable  cell,  cylindrical  in  shape,  with 
rounded  ends,  one  to  four  microns  long  (o.ooi  to  0.004 
mm.),  or,  say,  10,000  to  25,000  to  the  inch,  and  per- 
haps a  third  as  wide  as  it  is  long;  with  no  characteristic 
interior  structure,  no  indication  of  spores,  but  covered 
on  the  outside  with  numerous  long,  undulating  flagella 
which. give  the   cell  powers  of  lively  motion  in  liquid 


BACTERIOLOGY    OF    T^THOID    FEVER.  9 

media.     The  germs  multiply  by  fission,  —  that  is,  by  cross 
splitting,  —  each  cell  becoming  two,  and  each  two,  four. 


Ordinary  Appearance. 


Stained  to  show  the  Flagella. 


Growth  of  the  Bacilli  in  the 
Spleen. 


Appearance  of  the  Bacilli  in  the 
Widal  Test,  before  and  after 
"  clumping." 


Fig.  2. 

THE    TYPHOID    FEVER    BACILLUS. 

Magnified  about  i,ooo  Diameters. 

and  so  on.      Under  the  microscope,  cells   may  be  often 
seen  in  the  act  of  dividing,  —  some  with  an  elongation. 


lO  TYPHOID    FEVER. 

some  with  a  slight  constriction,  and  some  appearing  as 
two  cells  attached;  occasionally  chains  of  divided  cells 
may  be  seen,  looking  like  links  of  microscopic  sausages, 
but  moving  with  a  serpentine  motion.  So  minute  that 
half  a  million  would  scarcely  cover  the  head  of  a  pin, 
they  have  enormous  vital  power,  and  they  increase  so " 
rapidly  in  certain  artificial  culture  media  that  in  two  or 
three  days  a  hundred  may  become  a  billion,  and  form 
colonies,  or  masses,  visible  to  the  naked  eye.  It  is  more 
by  the  study  of  these  mass  cultures  and  by  the  effect 
which  their  growth  produces  on  the  culture  media  than 
by  the  study  of  the  individual  cells,  that  the  germs  are 
identified.  Without  entering  into  the  details  of  bacte- 
riological technique,  suffice  it  to  say  that  by  the  com- 
bined study  of  morphology,  physiology,  and  cultural 
characteristics,  the  typhoid  bacillus  can  be  recognized 
in  the  laboratory,  isolated  in  pure  culture,  and  submitted 
to  various  tests  as  to  virulence,  and  longevity  in  various 
environments. 

Specific  Cause  of  the  Disease.  The  question  is  often 
asked,  How  do  we  know  that  the  so-called  typhoid 
bacillus  is  the  specific  cause  of  the  disease?  It  must  be 
admitted  that  the  direct  proof  is  not  as  complete  as  in 
the  case  of  some  infectious  diseases,  for  the  reason  that 
the  lower  animals  are  not,  so  far  as  known,  susceptible 
to  the  disease.  Horses,  dogs,  cats,  guinea  pigs,  rabbits, 
etc.,  do  not  have  typhoid  fever.  This  closes  the  door 
on  a  most  important  field  of  research.  The  proof,  there- 
fore, must  be  of  necessity  circumstantial  in  character, 
except  as  accident  has  resulted  in  the  direct  infection 
of  human  beings  with  pure  cultures  of  the  organisms 


BACTERIOLOGY   OF   TYPHOID   FEVER.  II 

isolated  and  cultivated  from  a  previous  case  of  typhoid. 
But,  though  largely  circumstantial,  the  evidence  is  never- 
theless of  the  very  strongest  kind. 

The  Eberth  bacillus  can  be  isolated  from  persons  sick 
or  who  have  been  sick  with  typhoid  fever,  and  from 
those  persons  only.  It  is  present  in  the  blood  and  is 
found  in  enormous  numbers  in  the  urine  and  feces  of 
typhoid  patients.  Water  infected  with  such  discharges 
has  repeatedly  been  found  to  cause  the  disease  in  others. 
Peculiar  and  intimate  relations  have  been  established 
between  the  blood  serum  of  typhoid  patients,  or  of 
those  who  have  recently  had  the  disease;  and  pure  cul- 
tures of  the  Eberth  bacilli.  Such  blood,  when  added 
to  broth  cultures  of  the  bacilli,  causes  a  cessation  of 
motility  and  a  clumping,  or  agglutination,  of  the  organ- 
isms not  produced  by  the  blood  of  a  person  who  has 
not  had  the  disease.     (Fig.  2.) 

Although  animals  do  not  suffer  from  the  disease  of 
typhoid  fever,  laboratory  experiments  have  demon- 
strated that  cultures  of  highly  virulent  typhoid  bacilli 
introduced  into  rabbits  and  guinea-pigs  have  produced 
some  of  the  symptoms  of  the  disease  and  have  caused 
death.  In  these  experiments  the  most  pronounced 
pathological  conditions  have  been  in  the  region  of  the 
intestines,  and  in  some  cases  the  bacilli  have  been 
recovered  from  the  affected  parts.  In  general,  however, 
animal  experimentation  has  given  negative  rather  than 
positive  results.  There  are,  however,  a  few  cases  on 
record  where  typhoid  fever  has  been  contracted  by 
workers  in  the  laboratory  who  accidentally  became 
infected  with  cultures  of  the  bacillus. 


12  TYPHOID    FEVER, 

In  spite  of  lack  of  direct  experimental  proof  that  the 
bacillus  of  Eberth  is  the  specific  inciting  cause  of  typhoid 
fever,  the  circumstantial  evidence  is  so  strong  that  bac- 
teriologists and  sanitarians  are  satisfied  that  this  bacillus 
is  the  true  and  only  cause  of  the  disease. 

Portals  of  Entry.  The  typhoid  bacillus  enters  the 
body  through  the  mouth,  by  ways  hereafter  described, 
and  passes  through  the  stomach  into  the  intestines. 
That  the  germ  can  enter  the  body  through  any  other 
portal  than  the  mouth  and  intestinal  tract  is  doubtful, 
although  some  pathologists  have  claimed  that  in  rare 
cases  it  enters  'through  the  lungs. 

The  gastric  juice,  because  of  its  acid  character,  tends 
to  destroy  the  bacillus,  and  this,  no  doubt,  prevents 
many  a  case  of  the  fever.  There  would  seem  to  be 
some  advantage,  then,  in  drinking  water,  if  its  quality 
is  suspicious,  at  the  close  of  a  meal  rather  than  before 
or  between  meals.  Typhoid  bacilli  taken  into  the 
stomach  at  a  time  when  there  is  a  vigorous  secretion  of 
the  gastric  juice  probably  stand  less  chance  of  reaching 
the  intestines  alive  than  if  swallowed  at  times  when  the 
stomach  is  riot  performing  its  digestive  functions. 

Multiplication  in  the  Body.  Having  arrived  in  the 
intestines  the  bacilli  find  conditions  more  favorable 
for  growth,  and  especially  so  in  the  lower  third  of  the 
small  intestines,  where  the  inflammation  and  ulceration 
are  most  conspicuous.  Just  what  occurs  is  not  known, 
but  it  is  thought  that  they  force  their  way  through 
the  enfeebled  membranes,  enter  the  lymph  and  blood- 
channels,  and  are  swept  on  through  them  to  the  spleen 
and  other  parts  of  the  body.     Multiplying  in  the  so- 


BACTERIOLOGY   OF   TYPHOID    FEVER.  13 

called  Peyer's  patches  and  the  glands  of  the  intestines, 
the  bacilli  produce  the  characteristic  ulcers.  They 
accumulate  in  the  spleen  in  enormous  numbers,  giving 
rise  to  a  characteristic  congestion  of  that  organ;  they 
may  also  accumulate  in  the  liver,  the  gall  bladder,  the 
kidneys,  the  bladder;  they  have  been  found  even  in  the 
lungs,  the  meninges,  the  saliva,  the  rose-spots,  the  mar- 
row of  the  bones,  and,  what  is  of  great  importance,  the 
blood.  It  is  even  believed  by  some  that  gall  stones  are 
of  typhoidal  origin. 

Recent  studies  have  shown  that  the  germs  are  present 
in  the  blood  in  practically  all  cases  during  the  entire 
course  of  the  disease,  but  they  are  especially  evident 
during  the  early  stages.  In  fact  some  pathologists  go 
so  far  as  to  state  that  during  the  first  week  of  the  disease 
typhoid  fever  is  a  septicaemia.  Coleman  and  Buxton, 
who  have  made  a  careful  investigation  of  this  subject, 
have  given  data  showing  that  in  over  a  thousand  cases  in 
which  the  blood  was  examined,  89  per  cent  were  found 
to  have  the  germ  in  the  blood  during  the  first  week, 
73  per  cent  during  the  second  week,  60  per  cent  during 
the  third,  38  per  cent  during  the  fourth,  and  26  per  cent 
after  the  fourth  week.  They  found  that  the  period 
during  which  the  germ  was  present  in  the  blood  corre- 
sponded to  the  duration  of  the  fever  symptoms.  The 
appearance  of  the  germs  in  the  blood  marks  the  onset 
of  the  disease,  while  their  disappearance  from  the 
blood  marks  the  beginning  of  convalescence.  Some 
think,  however,  that  the  bacilli  do  not  multiply  in  the 
blood,  but  that  on  the  contrary,  they  "  overflow  " 
from  the  spleen  and  other  organs   into   the   blood   and 


14  TYPHOID    FEVER. 

there  die  and  liberate  the  toxin  against  which  the  body 
reacts. 

Just  how  the  typhoid  bacilli  penetrate  the  tissues 
of  the  intestines  and  get  into  the  lymphatic  system  is 
not  well  known.  That  many  persons  take  the  germs 
into  their  system  without  succumbing  to  the  dis- 
ease seems  certain.  That  persons  whose  systems  are 
run  down  or  enfeebled  from  overwork  or  exposure  take 
the  disease  easier  than  persons  in  robust  health  is 
also  certain;  but  that  persons  in  robust  health  do  not 
contract  the  disease  is  far  from  being  the  case.  A 
recent  theory  which  has  been  accepted  by  some  German 
pathologists  is  that  the  invasion  of  the  intestinal  walls 
by  the  typhoid  bacillus  is  due  to  the  presence  of  certain 
intestinal  parasites,  or  worms,  which  penetrate  the  walls 
and  thus  allow  the  bacilli  to  enter.  American  patholo- 
gists have  not  as  yet  accepted  this  theory,  and  the  weight 
of  evidence  appears  to  be  against  it.  Another  theory  that 
is  attracting  the  attention  of  pathologists  is  that  much  of 
the  so-called  summer  typhoid  is  due  to  the  occurrence 
of  other  intestinal  disorders  which  act  as  exciting  causes, 
rendering  the  intestines  more  susceptible  to  the  inva- 
sion of  the  typhoid  bacilli  than  at  other  times.  Another 
theory  is  that  improper  diet,  giving  rise  to  a  congestion 
of  the  liver,  may  reduce  the  secretion  of  bile  and  thus 
deprive  the  intestinal  tract  of  a  natural  disinfectant 
which  tends  to  prevent  adventitious  bacteria  from  caus- 
ing trouble.  Others  believe  that  the  white  blood  cor- 
puscles act  as  carriers  of  the  bacilli  from  the  intestines 
into  the  lymphatic  system.  Still  another  idea  is  that  a 
first  infection  predisposes  a  person  to  acquire  the  disease 


BACTERIOLOGY   OF   TYPHOID    FEVER.  1 5 

after  a  subsequent  infection  and  that  this  "hypersensi- 
tiveness"  has  much  to  do  with  the  incubation  period  of 
the  disease,  —  the  original  attack  rendering  the  blood 
susceptible  to  its  greater  infection  when  the  bacteria 
"overflow"  from  the  spleen. 

These  and  similar  theories  have  yet  to  be  proved. 
They  may  be  more  or  less  true,  and  some  of  them 
certainly  seem  reasonable;  but  it  is  hardly  necessary 
to  resort  to  them,  in  view  of  the  kno^Mi  ability  of  the 
tubercle  bacillus  to  pass  through  the  intestinal  mem- 
branes, and  of  the  demonstrated  ability  of  the  typhoid 
bacillus  to  pass  through  parchment  and  collodion  mem- 
branes. 

Typho-toxin.  During  their  growth  the  typhoid  bacilli 
are  active  in  producing  a  specific  toxin  which  is  liberated 
in  the  blood,  and  it  is  the  reaction  of  the  body  against 
this  which,  in  great  measure,  is  responsible  for  the  well- 
known  symptoms  of  the  disease.  Depressing  the  powers 
of  vital  resistance,  various  organs  become  affected,  and 
bronchitis  or  pneumonia  may  become  established,  the 
heart  action  may  be  weakened,  and  the  nervous  system 
deranged.  Typhoid  fever  is  therefore  a  disease  which 
operates  partly  by  the  direct  influence  of  the  bacteria, 
and  partly  by  the  indirect  influence  of  the  poison  which 
they  produce. 

Natural  Defenses  of  the  Body.  As  a  natural  defensive 
reaction  against  further  invasion  of  the  typhoid  bacilli, 
there  is  to  be  found  in  the  blood-serum  of  typhoid  patients 
a  bacterioh-tic  substance  which  is  inimical  to  the  growth 
of  the  organism.  The  nature  of  this  substance  is  still 
shrouded  in  mystery,   just  as  is  the  nature  of  typho- 


1 6  TYPHOID    FEVER. 

toxin  itself,  but  that  it  tends  to  destroy  the  typhoid 
bacilli  seems  certain;  though  whether  it  neutralizes  the 
effect  of  the  poison  which  they  produce,  is  less  certain. 
It,  no  doubt,  plays  an  important  part  in  checking  the 
disease  and  in  rendering  patients  immune  from  a  second 
attack.  Attempts  have  been  made  to  take  advantage 
of  this  "antibody  "  to  effect  both  prevention  and  cure  of 
the  disease,  but  thus  far  with  little  or  no  success.  It 
has  proved  very  useful,  however,  in  diagnosing  cases  of 
typhoid  fever  by  means  of  the  so-called  Widal  test, 
often  referred  to  as  the  "blood  test  for  typhoid  fever." 
Widal  Test.  If  a  drop  of  blood  from  a  person  who 
has,  or  who  has  recently  had,  typhoid  fever  be  mixed  with 
30  drops  of  sterile  distilled  water,  and  a  drop  of  this  mix- 
ture added  to  a  drop  of  a  broth  culture  of  typhoid  bacilli, 
and  examined  under  the  microscope,  it  will  be  noticed 
that  after  a  few  minutes  the  bacilli,  which  at  first  are 
motile  and  are  uniformly  scattered  over  the  field  of 
view,  gradually  become  motionless,  and  then  aggregate 
themselves  into  compact  masses.  This  is  known  as  the 
phenomenon  of  agglutination,  or  "clumping."  This 
will  not  happen  with  the  blood  of  a  person  not  ill  with 
the  disease,  or  one  who  has  not  recently  had  it;  nor  will 
it  ordinarily  happen  during  the  first  few  days  of  the  dis- 
ease. Neither  will  it  happen  if  the  blood  of  a  typhoid 
patient  is  mixed  with  a  culture  of  some  other  organism.  ^ 
A  positive  Widal  test  obtained  on  the  blood  of  a  sus- 
pected case  —  that  is,  one  in  which  clumping  is  observed 
—  is  therefore  practically  conclusive  evidence  that  the 

'  There  are  some  exceptions  to  these  general  statements,  but  they  do 
not  militate  against  the  main  propositions. 


BACTERIOLOGY    OF    TYPHOID   FEVER;  1/ 

disease  is  typhoid  fever.  Conversely,  the  blood-serum 
of  a  person  known  to  have  had  typhoid  fever,  or  of  an 
animal  which  has  been  rendered  immune  to  the  effect 
of  injected  cultures  of  the  organisms,  may  be  used  to 
establish  the  identity  of  an  unknown  culture  of  bacteria, 
although  this  test  is  less  definite  in  its  results  than  the 
other.  Various  modifications  of  the  original  Widal 
test  are  now  practiced.  Dead  cultures  are  used  instead 
of  the  living  typhoid  bacilli,  and  the  precipitation  of 
the  clumped  bacteria  in  mass  is  substituted  for  the 
microscopical  examination,  thus  simplifying  the  test, 
though  probably  at  the  sacrifice  of  accuracy. 

Blood  Tests.  Perhaps  a  better  test  than  the  Widal 
reaction  is  the  direct  examination  of  the  blood  for  the 
presence  of  the  typhoid  bacillus.  This  is  accomplished 
by  drawing  a  small  quantity  of  blood  from  the  ear  or 
from  a  vein  at  the  bend  of  the  elbow  into  an  all-glass 
syringe,  and  putting  from  i  to  3  cubic  centimeters  of  it 
into  a  flask  containing  20  cubic  centimeters  of  sterile 
ox-bile  culture  medium,  and,  after  cultivation,  examin- 
ing this  for  the  presence  of  the  typhoid  bacillus  accord- 
ing to  the  method  described  on  page  322. 

Modes  of  Exit.  That  the  typhoid  bacilli  are  present 
in  the  body  of  every  patient  has  been  firmly  established. 
How  do  they  leave  the  body?  In  what  numbers?  In 
what  condition  ?  How  long  do  they  persist  ?  These  and 
similar  questions  are  of  great  importance  in  considering 
the  spread  of  the  disease. 

As  typhoid  fever  is  very  largely  a  disease  of  the  intes- 
tines, the  bacilli  ought  obviously  to  be  found  in  the  dis- 
charges   of    the   bowels.     Bacteriological   studies    have 


1 8  TYPHOID   FEVER. 

shown  that  they  are  so  found.  They  are  especially 
abundant  during  the  earher  stages  of  the  disease,  but 
decrease  in  numbers  as  the  patient  convalesces.  They 
are  more  numerous  in  diarrheal  discharges  than  in  the 
more  solid  lumps  of  fecal  matter.  How  long  they  persist 
in  the  bowel  discharges  after  the  patient  is  well,  is  not 
known,  and  the  period  naturally  varies  greatly  in  dif- 
ferent individuals.  In  most  cases  no  danger  is  to  be 
feared  after  the  patient  has  recovered;  but  it  is  the  part 
of  wisdom  to  consider  the  stools  as  suspicious,  and  to 
maintain  disinfection,  for  at  least  two  weeks  after 
apparent  recovery.  In  the  "typhoid  carriers"  the  feces 
may  be  infected  for  months  and  even  for  years. 

No  reliable  figures  are  to  be  obtained  for  the  number 
of  bacilli  in  the  bowel  discharges,  but  the  numbers  for 
a  single  evacuation  may  easily  exceed  one  billion;  and 
there  is  ample  reason  to  believe  that  the  bacilli  leave  the 
body  in  a  living  and  virulent  condition. 

The  presence  of  the  bacilli  in  the  kidneys  and  bladder 
of  many  patients  naturally  causes  the  urine  to  become 
infected.  Until  within  a  few  years  this  was  overlooked, 
and  the  disinfection  of  urine  was  not  considered  as  of 
great  importance.  Although  the  urine  is  not  infected 
in  all  cases,  it  is  now  considered  that  its  disinfection  is 
even  more  important  than  that  of  the  feces.  Whenever 
the  urine  is  infected,  the  numbers  of  typhoid  fever  bacilli 
found  in  it  are  enormous.  Sternberg  cites  a  case  where 
each  cubic  centimeter  of  a  patient's  urine  contained 
175,000,000  bacilli.  This  would  amount  to  approxi- 
mately 200,000,000,000  a  day.  Furthermore,  the  bacilli 
frequently  persist  in  the  urine  for  several  weeks  after 


BACTERIOLOGY    OF    TYPHOID    FEVER.  1 9 

convalescence  and  after  the  practice  of  disinfection  is 
ordinarily  discontinued.  For  these  reasons  urinary 
infection  is  more  to  be  feared  than  fecal  infection. 

In  some  cases  the  bacilli  are  found  in  the  mouth  and 
throat.  Consequently  the  saliva  may  contain  them. 
This  condition  may  be  infrequent,  but  it  is  always  liable 
to  occur. 

There  is  practically  no  danger  to  be  feared  from  the 
quietly  exhaled  breath,  as  bacteria  do  not  readily  leave  a 
moist  surface;  but  coughing  or  sneezing  may  cause  the 
expulsion  of  the  bacilli  into  the  atmosphere,  with  conse- 
quent dangers  to  persons  in  the  room  who  may  inhale 
them.  The  sputum  of  a  typhoid  patient  is  likewise  a 
possible  source  of  infection,  especially  in  those  cases 
where  pneumonic  symptoms  are  prominent. 

The  bacilli  have  been  found  in  the  perspiration;  and 
although  the  danger  from  this  source  is  probably  quite 
remote,  it  is  one  that  ought  not  to  be  overlooked. 

Generally  speaking,  it  may  be  said  that  it  is  chiefly  in 
the  urine  and  the  bowel  discharges  that  the  typhoid 
bacilli  leave  the  body  of  the  patient,  but  in  some  cases 
they  may  leave  by  way  of  the  nose  and  mouth,  or  by 
even  the  perspiration. 

Typhoid  Carriers.  While  it  seems  generally  true  that 
the  body  becomes  quite  free  of  typhoid  bacilli  within 
a  comparatively  short  time  after  recovery,  recent  studies 
have  shown  that  in  a  very  small  percentage  of  cases  the 
germs  may  persist  for  months  and  even  years.  Such 
persons  become  "typhoid  carriers."  They  may  be  in 
good  health,  and  yet  be  a  constant  source  of  danger  to 
others  —  all  the  more  dangerous  because  unsuspected. 


20  TYPHOID    FEVER. 

European  observers  found  that  about  3  per  cent  of 
1782  cases  examined  by  them  became  typhoid  carriers, 
and  a  few  cases  of  this  kind  are  on  record  in  this 
country.  One  of  the  best  known  is  that  of  "Typhoid 
Mary,"  a  cook  in  New  York  City,  who,  in  good 
heakh,  and  changing  from  place  to  place,  left  a  trail  of 
at  least  twenty-eight  typhoid  cases  in  the  houses  where 
she  had  served,  until  the  facts  were  finally  found  out.  • 
Bacteriological  studies  made  by  the  health  department 
showed  that  she  was  a  "typhoid  carrier."  Typhoid 
fever  bacilli  were  found  in  her  feces.  To  prevent  her 
from  being  a  further  menace  to  the  community,  the 
department  of  health  placed  her  in  a  hospital  and  are 
endeavoring  to  effect  a  permanent  cure. 

There  is  reason  to  believe  that  typhoid  carriers  may 
develop  from  "walking  cases"  and  even  from  those  who 
are  not  cognizant  of  having  had  the  disease.  Such  cases 
are  probably  quite  rare,  but  they  are  especially  danger- 
ous, and  no  doubt  account  for  some  of  the  "sporadic  " 
outbreaks,  that  is,  for  the  sudden  occurrence  of  the 
disease  in  places  where  it  was  never  before  known  to 
occur  and  where  there  was  no  apparent  cause. 


CHAPTER  III. 
THE  TYPHOID  PATIENT  AS  A  FOCUS  OF  INFECTION. 

Modern  sanitary  science  declares  that  every  case  of 
typhoid  fever  is  caused  by  an  infection  with  bacilli 
derived  from  some  previous  case  of  typhoid  fever. 
Sometimes  there  is  direct  contact  between  patient  and 
victim;  but  more  often  the  victim  is  unknown  to  the 
patient,  and  far  removed  in  time  and  space.  The  modes 
of  conveyance  of  the  bacilli  may  not  always  be  known, 
but  the  "bactenotogyn^f -  to-day~ir[Slslf°llmt~there--m«&t_be 
'some  mode  of  conveyance,  and  that  the  disease  cannot  be 
produced  by  bad  air,  bad  water,  bad  food,  faulty  plumb- 
ing, or  by  climatic  conditions,  however  unfavorable, 
-4h^4:yphoidJ)acillus  is  involved. 

The  Endless  Chain.  Sanitary  science  declares  further 
that  every  case  of  typhoid  fever  is  potentially  a  focus 
of  infection;  that  virulent  bacilli  may  and  do  leave  the 
patient's  body;  and  that  unless  proper  precautions  are 
taken,  these  bacilli  may  become  scattered  in  various 
ways,  and  ultimately  give  rise  to  new  cases. 

In  former  days  the  spread  of  typhoid  fever  went  on  as 
an  endless  chain,  like  the  mailing  schemes  in  which  one 
sends  a  begging  letter  to  five  persons,  and  each  of  these 
sends  a  similar  letter  to  five  other  persons,  and  so  on. 
To  break  this  chain  as  near  as  possible  to  the  original 


22  TYPHOID    FEVER. 

link  is  the  aim  of  modern  sanitary  science.  It  is  a  task 
which  cannot  be  accomplished  single-handed;  it  requires 
the  cooperation  of  the  patient,  the  attending  physician, 
the  nurse,  the  members  of  the  household  of  the  patient, 
and  the  public  health  authorities.  Each  has  a  responsi- 
bility which  cannot  be  shifted  to  others. 

Barriers  against  Spread  of  the  Disease.  Every  typhoid 
case  should  be  surrounded,  as  it  were,  by  a  series  of 
barriers,  through  which,  in  order  to  escape,  the  typhoid 
germs  must  pass.  Should  the  germs  pass  the  first  line 
of  inclosure,  they  should  be  held  by  the  second;  and 
should  they  pass  the  second,  they  should  be  retained  by 
the  third.  If  these  barriers  could  be  faithfully  maintained 
the  -ravages  of  the  disease  would  soon  be  checked ;  but 
through  mischance  or  ignorance,  or  more  often  through 
negligence,  some  bacilli  do  escape  through  all  the 
barriers  and  become  scattered  at  large. 

Vehicles  of  Infection.  Through  various  agencies  the 
vagrant  germs  are  carried  to  their  victims.  Some  of 
these  agencies  are  well  known;  but  there  are,  no  doubt, 
others  not  yet  brought  to  light. 

Carriage  by  water  is  one  of  the  most  important  modes 
of  transmission,  and  the  one  which,  by  reason  of  the 
magnitude  of  its  effects  in  large  communities  and  the 
spectacular  character  of  frequent  epidemics,  has  most 
attracted  the  attention  of  the  public.  Transmission  by 
flies  from  infectious  matter  in  the  privy  to  food  in  the 
kitchen,  i.e.,  from  improperly  guarded  fecal  discharges 
to  unscreened  houses,  is  probably  of  common  occur- 
rence, especially  in  summer  and  in  rural  districts,  and 
may  be  one  of  the   chief  causes  of  the   summer  and 


FOCUS    OF    INFECTION.  23 

autumnal  typhoid.  It  has  come  to  be  well  recognized 
also  that  milk,  oysters  and  other  shell-fish,  raw  fruits 
and  vegetables  from  gardens  fertilized  by  human  ex- 
crement or  handled  by  persons  sick  of  typhoid,  may 
carry  the  bacilli. 

Contagion.  Nor  must  transmission  by  contact,  that 
is,  by  contagion,  be  overlooked.  A  patient  who  sneezes 
into  his  nurse's  face;  a  convalescent  who  handles  a 
piece  of  cake  or  some  dainty  and  passes  it  to  another 
member  of  the  family,  or  who  shakes  hands  with  a 
visiting  friend,  or  who  uses  the  "  family  towel,"  may 
unwittingly  spread  the  disease.  Typhoid  fever  is  both 
contagious  and  infectious. 

For  the  sake  of  clearness  and  emphasis,  these  various 
modes  of  transmission  are  expressed  diagrammatically  in 
the  frontispiece,  together  with  the  barriers  which  should 
surround  the  patient,  and  certain  lines  of  defense  which 
should  be  established  to  protect  other  individuals  from 
the  typhoid  bacilli  at  large. 

First  Barrier. 

The  first  fight  against  the  spread  of  typhoid  bacilli 
must  be  made  in  the  sick-room.  It  may  be  fairly  as- 
sumed that  the  patient  is  ignorant  of  the  nature  of 
his  disease  until  he  calls  the  doctor,  and  the  family 
physician  is  ordinarily  the  first  to  diagnose  the  case. 
The  initial  responsibility  for  preventing  the  scat- 
tering of  the  bacilli,  therefore,  rests  with  him. 

Duty  of  the  Physician.  The  first  duty  of  the  physician 
is,  of  course,  towards  his  patient;  but  his  second  is 
towards  the  other  members  of  the  household,  and  his 


24  TYPHOID    FEVER. 

third  to  the  community;  and  the  physician  who  neglects 
the  last  two  should  be  considered  guilty  of  malpractice 
as  truly  as  he  who  neglects  the  first.  The  conscientious 
physician  acts  in  a  dual  capacity,  —  as  medical  adviser 
and  as  sanitary  guardian  ex-oficio. 

Modern  medical  treatment  of  typhoid  fever  does  not 
aim  directly  at  destroying  the  bacilli  in  the  body,  but 
rather  towards  the  maintenance  of  normal  functions  in 
order  that  the  body  may  protect  itself.  From  the  stand- 
point of  the  patient  this  is  doubtless  the  proper  policy; 
but  there  is  good  reason  to  believe  that  without  injury 
to  the  patient,  physicians  can  do  much  more  than  they 
ordinarily  do  to  reduce  the  number  of  bacilli  discharged 
from  the  body.  Intestinal  disinfectants  have  little  or 
no  value  in  controlling  the  disease,  but  disinfection  of 
the  bladder  and  the  urinary  tract  by  the  use  of  urotropin 
and  similar  drugs  is  a  pronounced  success,  and  its  prac- 
tice ought  to  become  more  common  in  typhoid  cases. 
With  proper  precautions  the  danger  of  spreading  typhoid 
fever  by  infected  urine  could  be  largely  eliminated. 
Disinfecting  washes  for  the  mouth  might  also  be  of  some 
use,  but  in  most  cases  the  condition  of  the  patient  is 
such  that  they  could  not  be  used. 

Although  the  physician  can  do  much  to  prevent  the 
typhoid  bacilli  from  leaving  the  body  of  the  patient,  it 
cannot  be  expected  that  any  treatment  will  be  wholly 
effective.  Disinfection  of  the  discharges  is  therefore 
always  necessary,  and,  all  in  all,  it  is  the  most  important 
sanitary  precaution  to  be  taken. 

Duty  of  the  Nurse.  Disinfection  must  usually  be 
done  by  the  nurse  or  attending  member  of  the  family, 


FOCUS    OF    INFECTION.  2$ 

but  it  should  be  ordered  by  the  physician  according  to 
regulations  established  by  the  board  of  health.  The 
original  responsibility  is  with  the  physician.  As  soon 
as  it  is  even  suspected  that  a  case  is  one  of  typhoid 
fever,  disinfection  should  be  prescribed.  If  the  physician 
assumes  that  the  members  of  the  household  are  ignorant 
of  the  subject,  he  will  be  right  in  nine  cases  out  of  ten. 
He  ought  therefore  to  give  most  explicit  directions  as  to 
what  disinfectants  to  use  and  how  to  use  them.  Too 
often  the  physician's  directions  are  given  in  an  indefinite 
and  perfunctory  manner,  and  are  carried  out  in  the  same 
spirit.  Suppose  "chloride  of  lime  is  ordered":  the 
well-meaning  but  inefficient  attendant  sprinkles  a  Ifttle 
of  this  substance  around,  keeps  it  up  as  long  as  the 
patient  is  in  bed,  and  then  everybody  forgets  about 
it.  Suppose  he  "orders  corrosive  sublimate,"  and 
cautions  against  its  poisonous  character:  the  result  is 
that  the  attendant  is  either  too  much  scared  to  use  it  in 
a  proper  manner,  or  is  so  reckless  that  there  is  danger  of 
poisoning  the  whole  family.  He  may  "order  the  bedding 
to  be  disinfected":  and  this  may  be  done  a  few  times; 
but  if  the  laundress  finds  that  the  chemicals  are  rotting 
the  clothes  or  turning  them  dark,  as  will  doubtless 
happen,  the  practice  is  very  likely  to  be  given  up. 

Disinfection.  People  do  not  like  the  smell  of  chloride 
of  lime  or  carbolic  acid,  and  in  consequence  too  little 
of  these  chemicals  is  used,  and  the  period  of  contact  with 
the  matter  being  disinfected  is  insufficient.  In  some 
places  the  chemicals  recommended  by  physicians  can- 
not be  easily  obtained.  The  writer  recently  investi- 
gated an  epidemic  in  a  town  where  neither  chloride  of 


26  TYPHOID    FEVER. 

lime,  formaldehyde,  or  even  corrosive  sublimate  could 
be  obtained,  even  though  the  town  had  a  drug-store. 
The  question  of  expense  also  enters  into  the  problem  in 
some  cases. 

The  result  of  this  is  that  in  the  majority  of  typhoid 
cases  which  occur  among  the  poorer  classes,  disinfection 
as  now  conducted  by  the  "doctor's  orders"  is  a  mere 
farce,  while  among  the  more  intelligent  people  it  is 
often  insufficient.  Few  indeed  are  the  physicians  who 
closely  follow  up  their  first  instructions  and  personally 
see  that  they  are  carried  out. 

Nor  ought  they  to  be  required  to  do  so  outside  of  the 
house.  The  disinfection  and  disposal  of  typhoid  excreta 
is  a  matter  of  public  concern,  and  should  be  supervised 
by  the  local  board  of  health,  just  as  much  as  rooms  in 
which  diphtheria  and  scarlet  fever  cases  have  been 
confined  are  disinfected.  It  cannot  be  expected  that 
the  actual  work  be  done  by  a  public  health  agent,  as  it  is 
something  which  requires  attention  several  times  a  day; 
but  the  board  of  health  should  furnish  the  chemicals, 
and  see  that  they  are  used  in  a  proper  manner.  In  this 
matter  physicians  and  the  board  of  health  should  act  in 
harmony.  The  board  of  health  should  prescribe  the 
method  to  be  used,  and  the  physician  should  act  as  its 
agent  in  instructing  the  family  of  the  patient  as  to  the 
necessity  of  disinfection  and  as  to  the  modes  of  procedure. 

Report  to  Board  of  Health.  If  the  responsibility  for 
the  disposal  of  infectious  matter  is  to  rest  with  the  pub- 
lic authorities,  they  must  be  promptly  informed  as  to  the 
occurrence  of  the  disease.  In  many  states  and  in  most 
cities  the  sanitary  regulations  require  physicians  to  report 


FOCUS    OF    INFECTION.  27 

cases  of  typhoid  fever  as  they  occur;  but  there  is  an 
almost  universal  carelessness  among  physicians  in  report- 
ing cases,  which  is  most  discreditable  to  the  profession, 
as  it  shows  not  only  a  lack  of  appreciation  of  the  value 
of  public  sanitation,  but  an  utter  disregard  for  law. 
Study  of  statistics  shows  that  very  seldom  are  half  the 
urban  cases  of  typhoid  fever  reported  to  the  board  of 
health,  while  very  often  not  one  case  in  a  dozen  is  turned 
in.  Health  officers  who  are  responsible  for  the  enforce- 
ment of  the  registration  laws  should  be  far  more  strict, 
and  should  not  hesitate  to  exact  full  penalty  from  those 
physicians  who  fail  to  do  their  duty.  The  existence  of 
an  epidemic  in  a  community  is  frequently  not  recognized 
until  delayed  reports  accumulate  in  the  office  of  the 
board  of  health,  or  until  local  gossip  or  the  local  press  has 
called  attention  to  it.  Many  days  of  valuable  time  which 
might  have  been  used  in  searching  for  the  cause  of  the 
disease,  or  in  inaugurating  a  system  of  prophylactic 
measures,  are  thus  lost,  and  it  is  no  exaggeration  to 
state  that  many  lives  have  been  needlessly  lost  because 
of  the  failure  of  physicians  to  report  their  cases 
promptly. 

One  reason  for  greater  slowness  in  the  reporting  of 
typhoid  fever  cases  than  those  of  other  diseases  is  the 
uncertain  character  of  the  disease  in  the  early  stages 
and  the  lack  of  well-defined  symptoms.  Some  allow- 
ance must  be  made  for  this;  but  if  suspected  cases  were 
reported,  the  authorities  could  often  be  of  assistance  to 
the  doctor  by  making  blood  tests  and  analyses  of  fecal 
matter  to  confirm  or  disprove  the  diagnosis. 

There  are  three  things,  therefore,  which  the  physician 


28  TYPHOID    FEVER. 

can  do  to  prevent  the  spread  of  typhoid  bacilH:  first, 
to  adopt  such  measures  with  the  patient  as  to  reduce 
as  far  as  possible  the  number  of  bacilli  which  leave 
the  body;  second,  to  order  the  disinfection  of  the  feces, 
the  urine,  the  sputum,  the  bedding,  etc.,  according  to  the 
requirements  of  the  board  of  health;  and  third,  to 
report  the  case,  as  soon  as  suspected,  to  the  board  of 
health,  in  order  that  the  public  authorities  may  supply 
the  needed  disinfectants  and  superintend  the  disposal  of 
infectious  matter.  This  work,  for  which  the  physician 
is  responsible,  constitutes  the  first  barrier  against  the 
spread  of  the  disease. 

Second  Barrier. 

Duty  of  the  Household.  If  the  walls  of  the  sick- 
room mark  the  boundaries  of  the  first  barrier,  the  second 
line  of  inclosure  is  that  which  surrounds  the  premises 
in  which  the  patient  dwells.  Some  typhoid  bacilli  are 
sure  to  pass  out  of  the  sick-room,  and  upon  the  nurse 
and  attending  members  of  the  family  devolves  the  real 
task  of  extermination  and  control.  The  need  of  this 
task  will  be  understood  from  what  has  been  said  regard- 
ing the  exit  of  the  typhoid  germs  from  the  body  of  the 
patient,  and  the  various  modes  of  conveyance  of  these 
germs  to  new  victims;  but  for  the  sake  of  emphasis  they 
may  be  listed  as  follows: 

1.  Disinfection  of  fecal  matter. 

2.  Disinfection  of  urine. 

3.  Disinfection  of  sputum  and  vomited  matter. 

4.  Disinfection    of    water    used    in    bathing    the 

patient. 


FOCUS   OF   IXFECTIOX.  29 

5.  Disinfection  of  bedding,  clothing,  towels,  nap- 

kins,   handkerchiefs,    sponges,    used    about 
the  patient. 

6.  Disinfection  of  knives,  forks,  spoons,  cups,  etc., 

used  by  the  patient. 

7.  Disinfection  of  the  hands  of  the  attendants, 

8.  Proper  disposal  of  feces,  urine,  etc.,  by  burial 

in  the  ground,  or  in  water-closet  or  privy,  as 
occasion  demands. 

9.  Disinfection  of  water-closet  or  privy  seats,  and 

privy  vaults  and  cesspools. 
10.     Screening  of  privy  vaults  to  prevent  access  of 
flies. 

They  might  be  summed  up,  however,  in  two  words,  — 
disinfection  and  cleanliness. 

Disinfectants.  The  disinfection  of  infectious  matter 
from  typhoid  patients  is  not  at  all  difiicult.  The  typhoid 
bacilli  do  not  form  spores  and  are  easily  killed.  The 
chemicals  required  are  not  expensive,  and  may  be 
easily  and  safely  manipulated.  It  is  necessary,  how- 
ever, to  use  the  disinfectants  in  large  enough  quantities, 
to  thoroughly  mix  them  with  the  discharges,  and  to 
give  them  time  enough  to  act. 

Many  different  disinfectants  have  been  recom- 
mended, —  chloride  of  lime,  corrosive  sublimate,  carbolic 
acid,  formaldehyde,  copperas,  blue  vitriol,  and  others, 
—  and  all  of  these  have  certain  special  advantages  in 
particular  cases;  but  all  in  all,  for  common  practical 
use,  there  is  no  better  substance  for  the  disinfection  of 
fecal  matter,  urine,  or  sputa,  or  for  use  in  privy  vaults 


30  TYPHOID    FEVER. 

or  cesspools,  than  slaked  lime  freely  used.  It  has  the 
important  advantage  of  cheapness  and  availability;  it  is 
without  odor,  and  is  such  a  well-knovm  substance  that 
no  one  fears  its  use.  It  is  conspicuously  white,  so  that 
its  use  is  evident  to  the  inspector.  Being  cheap,  it  is 
naturally  used  in  large  quantities,  and  this  insures  a.' 
more  intimate  contact  with  the  infected  matter.  The 
other  disinfectants  named  are  perhaps  more  active 
chemical  agents  than  lime,  and  smaller  amounts  may 
be  used;  but  chloride  of  lime  and  carbolic  acid  and  for- 
maldehyde all  have  odors  which  people  dislike,  while 
corrosive  sublimate  is  a  powerful  poison  and  has  to  be 
used  with  caution.  For  hospitals  and  for  cases  where 
trained  nurses  are  employed,  corrosive  sublimate  and 
carbolic  acid  are  perhaps  the  most  serviceable.  So,  too, 
for  the  cramped  quarters  of  city  apartments.  But  for 
use  in  isolated  country  houses,  and  among  the  more 
ignorant  class  of  people,  common  lime  is  preferable. 

In  disinfecting  the  typhoid  discharges,  especial 
attention  should  be  given  to  the  feces  in  the  earlier 
stages  of  the  disease,  and  to  the  urine  in  the  later  stages. 
Even  after  convalescence  the  urine  she  uld  be  disinfected 
for  several  weeks,  or  until  a  bacteriological  examination 
has  shown  it  to  be  unnecessary. 

Bedding  and  clothing  soiled  by  the  patient  should 
be  soaked  for  several  hours  in  a  solution  of  car- 
bolic acid  or  bichloride  of  mercury,  and  afterwards 
washed  in  boiling  water.  Handkerchiefs  should  be 
similarly  treated,  though,  preferably,  inexpensive  cloths 
should  be  used  for  the  sputa  and  afterwards  burned. 
Spoons,  cups,  and  other  articles  handled  by  the  patient 


FOCUS    OF    INFECTION.  '     31 

should  be  soaked  in  disinfectants  before  washing;  and, 
as  a  further  precaution,  certain  particular  articles  of  this 
character  should  be  set  apart  for  the  exclusive  use  of  the 
patient. 

Detailed  instructions  for  the  use  of  disinfectants  are 
given  on  page  287. 

Disposal  of  Fecal  Matter.  After  two  or  three  hours 
of  contact  with  the  disinfectants,  the  fecal  matter,  urine, 
etc.,  must  be  disposed  of.  WTiile  standing  they  should 
be  carefully  covered  to  protect  them  from  flies.  In 
houses  provided  with  water-closets  connected  with  the 
public  sewers  this  is  the  natural  and  proper  place  of 
disposal,  but  in  country  places  burial  in  the  earth  is 
preferable  to  disposal  in  a  privy  or  cesspool.  The  earth 
for  a  foot  or  more  down  from  the  surface  is  teeming  with 
bacteria  and  other  forms  of  life,  and  when  typhoid 
bacilli  are  buried  in  the  ground  they  are  soon  destroyed. 
Care  should  be  taken  in  the  selection  of  a  spot.  It 
should  not  be  near  a  weU,  nor  in  a  garden  where  garden 
truck  is  raised.  A  convenient  mode  of  burial  is  to  dig 
a  trench  a  foot  deep,  throwing  the  earth  to  one  side 
and  covering  each  deposit  as  soon  as  it  has  been  placed 
in  the  ground.  The  urine,  as  well  as  the  solid  matter, 
should  be  poured  into  the  trench  and  covered,  and 
not  poured  on  the  top  of  the  ground,  as  is  too  often 
done. 

During  the  winter,  when  the  ground  is  frozen  or 
covered  with  snow,  burial  in  the  earth  should  not  be 
attempted.  It  is  better  to  use  the  privy  or  cesspool,  and 
thoroughly  disinfect  it  and  clean  it  as  soon  as  there  is 
opportunity.      Above  all  things,  the  discharges   should 


32  TYPHOID    FEVER. 

not  be  put  on  top  of  frozen  ground.  This  procedure 
has  been  the  cause  of  some  of  the  most  severe  epidemics 
that  have  ever  occurred  in  this  country. 

If  the  discharges  are  thrown  into  a  privy  vault,  this 
should  be  thoroughly  disinfected  with  lime,  and  each 
new  deposit  should  be  immediately  covered  with  lime. 
The  back  of  the  vault  and  the  windows  and  ventilators 
of  the  privy  house  should  be  carefully  protected  from 
flies  by  means  of  screens;  all  cracks  should  be  covered 
with  paper  pasted  over  them;  a  self-closing  seat  cover 
should  be  used,  and  a  spring  should  be  placed  on  the 
door  to  render  it  self-closing. 

If  the  discharges  are  thrown  into  a  cesspool,  or  into  a 
water-closet  which  connects  with  one,  it  should  be  dis- 
infected most  thoroughly,  and  great  care  should  be  taken 
with  the  material  removed  at  subsequent  cleanings. 
In  fact,  to  guard  against  future  danger  the  cesspool 
should  be  emptied  and  disinfected  as  soon  as  the  infected 
sewage  has  ceased  to  flow  into  it. 

Cleanliness.  Above  all  things,  scrupulous  cleanli- 
ness is  required  on  the  part  of  the  attendants,  both  in  the 
interest  of  self-protection  and  that  of  preventing  the 
spread  of  the  disease  to  other  members  of  the  family. 
This  is  especially  necessary  in  the  sick-room.  A  drop  of 
urine  or  a  speck  of  fecal  matter  no  larger  than  a  pin-head 
may  contain  hundreds  of  thousands  of  bacilli;  hence 
care  against  the  spattering  of  such  matter  is  important. 
In  caring  for  a  patient,  the  hands  of  the  nurse  are  very 
likely  to  come  in  contact  with  infectious  matter.  Wash- 
ing and  disinfecting  the  hands  after  leaving  the  bedside 
are   therefore   demanded.     A   careless   attendant  going 


FOCUS    OF    INFECTION.  33 

from  the  bedside  to  the  kitchen  and  there  preparing  the 
family  meals  may  convey  the  disease  to  the  whole 
household.     Cases  are  on  record  where  this  has  occurred. 

Isolation.  The  isolation  of  the  patient  is  important. 
He  should  have  a  room  by  himself,  or  at  the  very  least 
a  bed  by  himself.  In  crowded  quarters  this  is  often 
difiicult  of  attainment.  The  author  once  saw  a  man 
sick  with  typhoid  fever  in  a  room  occupied  by  fifteen 
others,  there  being  four  beds  occupied  by  Hungarian 
laborers  who  worked  in  day  and  night  shifts,  and  the 
woman  who  took  care  of  the  beds  and  tended  the  patient 
prepared  the  food  for  the  sixteen  men.  In  such  a  case 
the  only  recourse  is  to  remove  the  patient  to  a  hospital. 

While  isolation  of  the  patient  is  desirable,  a  strict 
"quarantine,"  in  the  sense  in  which  the  word  is  gen- 
erally used,  is  unnecessary. 

The  sick-room  should  be  thoroughly  screened  to 
prevent  flies  from  carrying  about  the  infection. 

Children.  Children  should  not  be  permitted  to  run  in 
and  out  of  the  sick-room,  or  to  share  with  the  patient 
the  dainties  which  are  so  often  furnished.  Their 
inquisitiveness  and  their  innocent  desire  to  be  of  service 
to  the  sufferer  often  result  most  disastrously. 

The  convalescing  patient  must  remember  that  he  is 
liable  to  be  a  focus  of  infection  for  a  number  of  weeks 
after  he  leaves  his  bed,  and  should  take  unusual  care  not 
to  infect  other  members  of  the  family. 

The  work  of  disinfection  and  the  care  exercised  by  the 
household  of  the  typhoid  patient  thus  constitute  the 
second,  and  most  important,  barrier  against  the  spread 
of  the  disease. 


34  TYPHOID    FEVER. 

Third  Barrier. 

Duty  of  Public  Authorities.  The  final  responsibility 
for  the  prevention  of  the  spread  of  typhoid  fever  rests 
with  the  public,  acting  through  the  board  of  health,  or 
the  health  officer,  or  other  properly  constituted  authority.- 
This  demands  the  exercise  of  various  activities,  such  as,  — 

1.  Consideration  of  reports  of  physicians. 

2.  Diagnostic  tests. 

3.  Supervision  of  the  disposal  of  infectious  matter. 

4.  Distribution  of  disinfectants. 

5.  Purification  of  sewage. 

Before  the  board  of  health  can  act  in  a  case  of  typhoid 
fever,  it  must  have  a  knowledge  of  the  existence  of  the 
case,  which  should  come  to  it  from  the  physician. 
Stringent  laws  requiring  doctors  to  report  their  cases 
promptly  should  be  passed  and  rigidly  enforced. 

Many  doctors  hesitate  to  report  cases  for  fear  that 
their  reputation  may  suffer  through  an  occasional  faulty 
diagnosis.  If,  however,  the  law  required  suspected 
cases  of  typhoid  fever  to  be  reported,  there  would  be  no 
such  feeling;  and  if  a  second  report  should  reverse  the 
decision  of  the  first,  or  if  the  blood  test  should  give  a 
negative  result,  no  harm  would  be  done.  The  failure  to 
report  a  case  of  real  typhoid  fever  works  far  greater 
damage  than  the  report  of  a  suspected  case  which  proves 
to  be  something  else. 

System  of  Reporting.  Everything  should  be  done  to 
make  the  work  of  reporting  typhoid  cases  as  easy 
and  automatic  as  possible.     Physicians  are   busy   men, 


FOCUS   OF    INFECTION.    '  35 

irregular  in  tlieir  hours,  and  often  away  from  home  for 
a  large  part  of  the  day.  Suitable  postal  card  blanks, 
stamped  and  addressed,  should  be  freely  supplied  to 
the  doctors,  and  arrangements  should  also  be  made  for 
report  by  telephone.  The  nature  of  the  physician's 
report  is  referred  to  on  page  218. 

Blood  Tests.  The  board  of  health,  having  received 
the  report  of  a  suspected  case,  should  be  prepared  to 
verify  the  same.  This  involves  the  application  of  the 
Widal  test  to  the  blood  of  the  patient,  or  some  equivalent 
test,  and  requires  the  services  of  a  bacteriologist  and  a 
laborator}^  equipment.  Most  of  the  large  cities  are 
now  able  to  do  this  work;  but  in  the  case  of  small  com- 
munities which  cannot  assume  the  entire  expense,  it 
should  be  done  by  the  county  or  state,  or  conducted  on 
some  cooperative  basis.  Results  of  these  tests  would 
not  only  be  of  great  assistance  to  the  physician,  but 
they  would  greatly  strengthen  the  position  of  the  board 
of  health  in  the  matter  of  disinfection.  The  board  of 
health  should  also  be  prepared  to  make  bacteriological 
examinations  of  the  feces  and  urine  of  convalescing 
patients.  These  tests  are  coming  to  be  regarded  as  quite 
as  important  as  the  "Widal  test. 

Supervision  over  Disinfection.  The  board  of  health 
should  maintain  a  general  supervision  over  the  dis- 
infection of  typhoid  excreta,  and  should  establish  regu- 
lations and  secure  the  cooperation  of  the  physicians 
in  having  them  carried  out.  It  should  provide  all 
needed  disinfectants  and  distribute  them  in  proper 
receptacles,  accompanied  by  simple  but  full  directions 
for  use.     The  gain  to  .the   community  by  this   public 


36  TYPHOID    FEVER. 

distribution  of   disinfectants  would    more    than  justify 
its  cost. 

Sewage  Disposal.  Leaving  the  household  we  now 
come  to  the  larger  question  of  the  disposal  of  the  sew- 
age and  other  wastes  of  the  community.  These  are 
emphatically  public  matters,  though  they  fall  within  the 
domain  of  the  engineering  departments  of  a  city  rather 
than  that  of  the  department  of  health  as  ordinarily 
constituted. 

A  number  of  years  ago,  a  sewerage  system  was  con- 
sidered to  be  complete  if  it  satisfactorily  collected,  with- 
out nuisance,  the  sewage  from  the  houses  and  let  it  go 
somewhere,  anywhere,  into  the  harbor,  into  the  lake,  or 
into  "the  river,  according  to  situation,  —  out  of  sight,  out 
of  mind.  Sewer  gas  was  regarded  as  dangerous;  the 
sewer  liquid  was  regarded  merely  as  a  nuisance.  Now 
this  is  reversed,  and  the  liquid  sewage,  germ-laden"  and 
infected,  is  known  to  be  the  thing  to  be  most  feared. 
Sewage  disposal  is  therefore  now  looked  upon  as  quite 
as  important  as  sewage  collection.  Recent  years  have 
seen  some  extraordinary  developments  in  the  art  of 
sewage  purification,  and  coming  years  are  destined  to 
see  far  greater  advances. 

There  is  a  good  deal  of  misconception  about  the 
subject  of  sewage  disposal.  Sanitary  problems  are  not 
necessarily  involved,  although  they  usually  are  to  some 
extent.  In  some  places  it  may  be  merely  a  question  of 
nuisance,  —  and  it  must  be  remembered  that  a  stream 
which  has  bad  odors  and  which  is  offensive  to  the  sight 
will  not  cause  typhoid  fever,  unless  the  typhoid  germs  are 
in  the  water,  and  unless  the  water  gets  into  the  mouth. 


FOCUS   OF   INFECTION.  37 

This  is  not  the  place  to  discuss  the  general  subject  of 
sewage  disposal,  but  a  few  facts  are  worthy  of  notice 
at  this  point. 

There  are  various  methods  of  sewage  purification, 
some  of  them  of  modern  date,  involving  septic  tanks, 
chemical  precipitation  basins,  contact  beds,  sprinkling 
filters,  etc.  These  and  similar  agencies  are  usually 
installed  for  the  purpose  of  improving  the  chemical 
character  of  the  sewage,  and  to  prevent  its  subsequent 
decomposition,  with  attendant  nuisances.  If  properly 
built  and  properly  operated,  and  enlarged  from  time  to 
time  according  to  need,  they  do  in  a  satisfactory  manner 
the  work  for  which  they  were  designed;  they  even  do 
more,  —  they  accomplish  a  marked  bacterial  purification 
of  the  sewage.  But  their  chief  function  is  to  destroy 
dead  organic  matter,  not  living  organisms,  —  although 
living  organisms  are  concerned  in  the  process.  They  do 
not  render  sewage  fit  to  drink;  and  if  the  effluent  is  turned 
into  a  stream  used  for  drinking,  some  danger  of  con- 
tamination still  remains.  Such  systems  reduce  the 
danger  of  contamination,  but  they  do  not  wholly 
remove  it.  In  this  respect  the  old  systems  of  purifica- 
tion by  intermittent  filtration  and  broad  irrigation  are 
more  to  be  depended  on,  but  even  these  processes  are 
not  complete. 

There  is  a  growing  feeling  among  sanitarians  that  noth- 
ing less  than  a  secondary  filtration  of  a  sewage  effluent, 
carried  out  substantially  on  the  lines  of  water  purification, 
or  a  disinfection  of  the  effluent  by  means  of  chemicals, 
is  necessary  in  order  to  render  sewage  free  from  patho- 
genic bacteria. 


38  TYPHOID    FEVER. 

Whether  or  not  the  sewage  of  a  city  or  town  should  be 
purified  to  such  a  degree  as  to  destroy  pathogenic  bacteria, 
is  a  question  which  must  depend  upon  the  local  surround- 
ings, and  must  be  decided  independently  for  each  particu- 
lar case.  If  the  sewage  of  a  city  flows  into  a  stream  used 
in  its  lower  reaches  for  purposes  of  public  water-supply, 
that  city  is  at  least  morally  bound  to  keep  infectious 
matter  out  of  the  river. 

The  courts  are  beginning  to  decide  that  where  a  city 
is  supplied  with  public  sewers  the  municipality  is  respon- 
sible for  any  damage  occasioned  by  the  pollution  of  a 
stream  by  this  sewage.  Although  thus  far  this  decision 
has  been  applied  only  to  cases  of  nuisance,  in  time  it  may 
be  extended  to  cover  cases  of  infection. 

Disposal  of  Fecal  Wastes  on  Boats  and  Trains.  The 
disposal  of  water-closet  wastes  on  steamboats  and  trains 
is  something  that  demands  serious  consideration.  The 
pollution  of  the  water  of  lakes  from  steamboats  pass- 
ing near  a  water-works  intake,  and  the  scattering  of 
fecal  matter  along  the  road-bed  of  a  railroad,  passing 
over  some  water-shed  used  for  public  supply,  are  likely 
to  bring  disaster.  Although  the  chance  of  danger  may 
be  small  in  comparison  with  other  causes  of  typhoid 
fever,  yet  the  practice  is  unsanitary  and  disgusting.  In 
some  places  trains  passing  through  territory  tributary  to 
a  water-works  reservoir  are  compelled  to  have  their 
closet  doors  locked.  While  this  prevents  contamina- 
tion of  the  road-bed,  the  continual  damage  to  the  health 
and  comfort  of  passengers  by  reason  of  deprivation  of 
toilet  privileges  might  easily  be  a  more  serious  matter 
than  the  chancp  of  damage  done  to  some  water-supply. 


FOCUS   OF  INFECTION.  39 

The  practice  is  only  to  be  tolerated  as  a  temporary 
expedient.  What  is  needed  is  some  form  of  receptacle 
to  be  used  on  the  train  that  will  hold  the  urine  and 
excreta  until  they  can  be  safely  removed  at  the  end  of  the 
journey  or  at  some  intermediate  point.  There  is  cer- 
tainly ingenuity  enough  among  our  railroad  men  to 
provide  some  device  that  will  do  this  without  nuisance 
to  the  passengers.  The  present  toilet-room  arrange- 
ment in  the  ordinary  day  coaches  is  usually  an  abomi- 
nation. 

Care  of  Toilet-Rooms.  The  lack  of  care  of  the  toilet- 
rooms  in  most  railroad  stations  is  another  wrong  that 
needs  righting.  Used  promiscuously  by  the  careless, 
the  ignorant,  the  sick,  they  are  seldom  cleaned,  and 
rarely  or  never  disinfected,  while  flies  swarm  through 
the  windows,  and  vermin  crawl  on  the  floor.  This  is 
more  likely  to  be  the  case  in  small  way  stations  than  in 
the  terminal  stations  of  large  cities.  What  is  true  of 
railroad  toilet-rooms  is  true  to  some  extent  of  factories, 
schoolhouses,  and  public  buildings. 

All  such  toilet-rooms  open  to  the  public  or  used  by 
large  numbers  of  people  should  be  under  regular  inspec- 
tion by  the  health  authorities,  and  occasional  disinfection 
should  be  required  by  law. 

Flies.  The  public  authorities  can  help  to  prevent 
the  spread  of  typhoid  fever,  as  well  as  other  diseases, 
by  bringing  about  conditions  of  general  cleanliness. 
"Dirt  breeds  disease."  One  cannot  tell  how  far  this 
trite  saying  extends,  but  every  year  bears  new  testi- 
mony to  its  truth.  Flies,  which  may  be  often  the  means 
of  transmitting  typhoid  fever  germs,  develop  from  eggs, 


40  TYPHOID    FEVER. 

and  these  eggs  are  very  commonly  laid  in  manure  piles. 
Dr.  L.  O.  Howard,  the  entomologist  of  the  United  States 
Department  of  Agriculture,  states  that  the  house-fly 
prefers  horse-manure  as  a  breeding-place,  although  it 
may  breed  in  other  fecal  matter.  Dangers  may  arise 
from  the  location  of  stables  in  crowded  communities, 
and  hence  strict  rules  should  be  made  in  regard  to  the 
care  and  storage  of  manure.  The  disposal  of  garbage 
is  also  an  important  matter,  as  the  common  little  fruit- 
fly  is  likely  to  be  the  means  of  conveying  the  typhoid 
bacillus. 

The  war  on  flies  has  scarcely  begun;  when  it  does 
begin,  it  will  involve  many  reforms.  Among  these  will 
be  cleaner  streets,  and  especially  the  prompt  removal 
of  horse-manure,  better  care  of  stables,  better  care  of 
vacant  lots,  better  care  of  wharves  and  markets,  better 
protection  of  garbage  pails,  and  a  general  attempt 
to  eliminate  the  breeding-places  of  flies  and  insects. 
More  attention  will  be  given  to  screening  public  build- 
ings, schoolhouses,  hotels,  restaurants,  etc. 

In  these  various  ways  the  public  authorities,  represent- 
ing the  whole  people,  can  establish  a  final  and  exceed- 
ingly important  barrier  against  the  spread  of  the  typhoid 
bacillus. 


CHAPTER    IV. 
THE  TYPHOID  BACE^LUS  AT  LARGE. 

It  is  easier  to  keep  the  pig  from  getting  out  of  the  pen 
than  it  is  to  catch  him  when  he  is  out.  It  is  easier  to 
keep  the  sparks  from  scattering  from  the  fireplace  than 
it  is  to  put  out  the  conflagration  that  the  sparks  have 
kindled.  So,  also,  it  is  easier  to  prevent  the  germs  of 
typhoid  fever  from  leaving  the  sick-room  than  it  is  to 
avoid  them,  or  to  discover  and  destroy  them,  after  they 
are  out  of  bounds.  But,  in  spite  of  all  precautions, 
sparks  will  sometimes  scatter,  pigs  will  get  loose,  and 
typhoid  germs  will  escape  through  all  the  barriers. 
Our  next  study,  therefore,  must  be  the  typhoid  bacillus 
at  large. 

The  Typhoid  Bacillus  Outside  the  Body.  Bacillus  typhi 
is  essentially  a  parasitic  organism.  A  common  habitat, 
and  apparently  its  favorite  one,  is  the  human  body. 
There  it  may  find  for  a  time  conditions  favorable  for 
growth.  Unfortunately,  however,  it  does  not  die  as 
soon  as  it  leaves  the  body,  but,  unless  destroyed,  maintains 
a  vagabond  existence  in  various  places  and  for  various 
lengths  of  time,  ultimately  perishing  of  exposure  or 
starving  to  death,  or,  with  better  luck,  finding  once  more 
a  temporary  home  in  the  intestines  of  a  new  human  host. 
The    whole   story   of  the  saprophytic  existence    of  the 

41 


42  TYPHOID    FEVER. 

typhoid  bacillus  —  that  is,  its  life  outside  of  the  body  — 
is  far  from,  being  known,  but  much  has  been  learned 
during  the  last  ten  or  fifteen  years  regarding  its  longevity 
in  different  media,  and  the  influence  upon  it  of  heat  and 
cold,  dryness,  pressure,  oxygen,  food-supply,  poisons,  etc. 
How  long  will  the  typhoid  fever  bacillus  live  in  water? 
How  long  in  ice?  How  long  in  milk?  In  the  soil? 
In  ^oysters  ?  How  does  its  vitality  when  it  leaves  the 
body  affect  longevity?  And  how  does  environment 
affect  its  virulence?  These  are  some  of  the  questions 
which  the  sanitarian  needs  to  have  answered,  and  they 
are  among  the  most  difficult  and  complicated  problems 
which  the  bacteriologist  is  called  upon,  to  solve.  Little 
wonder  that  the  experiments  thus  far  made  have  not 
been  in  entire  accord  and  that  experts  have  sometimes 
disagreed  on  these  important  matters." 

Requirements  for  Growth.  The  three  principal  re- 
quirements for  bacterial  growth  are  food,  moisture,  and 
warmth,  but  many  other  factors  affect  longevity.  Some 
of  these  are  of  a  general  character,  but  most  of  them 
may  be  most  conveniently  discussed  under  the  heads  of 
water,  milk,  ice,  and  the  soil. 

Moisture.  Moisture  is  essential  to  the  growth  of  the 
typhoid  bacillus,  as  it  is  to  all  vegetable  life.  Drying 
is  for  this  organism  more  fatal  than  it  is  to  many 
forms,  and  even  a  short  period  of  desiccation  results  in 
death.  Some  bacteria,  as,  for  instance,  the  bacillus 
of  tetanus,  form  spores  which  are  provided  with  a 
firm  cell-wall  that  enables  them  to  withstand  drying. 
They  are  able  to  maintain  a  latent  existence,  as 
a   seed    does^  and   then,  after   a   period   of   inactivity, 


THE   TYPHOID    BACILLUS   AT   L.\RGE.  43 

when  the  conditions  become  favorable,  germinate  and 
multiply  once  more.  It  is  for  this  reason  that  the 
dried  sputum  of  a  consumptive  is  to  be  feared,  and  it  is 
for  this  reason  chiefly  that  dust  is  dangerous.  But,  so 
far  as  is  now  known,  the  typhoid  bacillus  does. not  form 
spores,  and  there  is  little  or  no  danger  to  be  feared  from 
dust  or  from  the  air,  unless  this  dust  or  this  air  has  had 
opportunity  for  recent  infection.  The  danger  from  dust 
should  not  be  wholly  ignored,  for,  although  no  spores  of 
the  typhoid  germ  have  ever  been  discovered,  experiments 
have  indicated  that  among  the  many  individual  cells  of 
a  culture,  a  few  often  seem  to  have  powers  of  resistance 
against  an  unfavorable  environment  far  above  the  gen- 
eral average.  Furthermore,  a  particle  of  dust  dried 
only  on  the  outside  may  harbor  living  germs  within. 
GeneraUy  speaking,  however,  drj^ing  kills  the  typhoid 
bacillus. 

Typhoid  germs  do  not  readily  leave  a  moist  surface. 
Sticky  by  nature,  they  adhere  until  desiccation  loosens 
their  dead  cells.  For  this  reason  sewer  air  is  not  to  be 
looked  upon  as  a  direct  means  of  infection.  Experi- 
ments have  shown  that  the  air  of  the  Paris  sewers  con- 
tains fewer  bacteria  than  the  air  in  the  streets  above 
them.  Laborers  who  work  in  sewers  are  not  more 
afflicted  with  air-borne  infectious  diseases  than  other 
laborers.  The  exhaled  breath  is  practically  sterile. 
One  may  blow  for  some  time  through  a  tube  into  a  sterile 
culture  medium  without  contaminating  it.  But  the 
constant  breathing  of  sewer  air,  or  "sewer  gas"  as  it  is 
often  called,  may  have  a  depressing  effect  on  the  system, 
and    render    one    less    liable    to    resist    infection.     The 


44  TYPHOID    FEVER. 

exhaled  breath  during  coughing  and  sneezing  may  con- 
tain a  spray  of  saHva  that  may  be  dangerous. 

Sunlight.  Sunlight  is  a  strong  germicide.  It  has 
been  often  shown  by  laboratory  experiments  that  cul- 
tures of  typhoid  bacilli  and  other  bacteria  exposed  to 
the  direct  rays  of  the  sun  in  a  window  are  quickly  killed 
or  their  numbers  greatly  reduced.  The  solar  energy 
is  a  powerful  aid  to  desiccation  in  rendering  dust  in- 
nocuous. "Letting  in  the  sunlight"  is  not  merely  a 
figure  of  speech,  it  is  one  of  the  most  powerful  and  ben- 
eficial of  sanitary  measures. 

It  is  a  common  belief  that  sunlight  exerts  a  potent 
influence  in  the  purification  of  water  in  lakes  and  streams. 
To  a  certain  extent  this  is  true,  but  its  effect  is  not  as 
great  as  one  might  naturally  expect,  and  often  it  is  nil. 
The  energy  of  the  sun's  rays  penetrating  a  body  of 
water  is  so  rapidly  absorbed  in  the  upper  strata  that 
even  at  a  few  feet  below  the  surface  it  has  only  a  very 
small  fraction  of  its  value  at  the  surface.  This  is  the 
case  in  clear,  colorless  water:  in  waters  which  are  muddy 
the  absorption  of  light  is  even  greater,  and  the  sterilizing 
effect  does  not  extend  more  than  an  inch  or  so  below 
the  surface.  Many  interesting  experiments  have  been 
made  to  determine  the  intensity  of  the  energy  of  the 
sun's  rays  as  they  pass  downward  into  bodies  of  water. 
Photographic  plates  have  been  exposed  at  different 
depths;  the  decolorization  of  water  has  been  studied; 
and  sealed  bottles  of  water  containing  known  numbers 
of  bacteria  have  been  kept  at  different  depths  for  equal 
intervals  of  time  and  the  numbers  of  bacteria  remaining 
ascertained.     All    of    these    experiments    indicate    that 


THE  TYPHOID  BACILLUS  AT  LARGE.  45 

whatever  sterilizing  influence  is  possessed  by  the  sun's 
rays  is  confined  to  a  very  thin  layer,  and  that  the  more 
turbid  or  discolored  a  water  is,  the  thinner  is  the  stratum 
affected. 

Temperature.  The  temperature  relations  of  the 
typhoid  bacillus  are  very  important.  The  most  favorable 
temperature  for  its  development  is  probably  that  of  the 
human  body,  namely,  about  98.6  degrees  F.,  or  37 
degrees  C.  At  much  higher  temperatures,  and  at  much 
lower  temperatures,  according  to  laboratory  experi- 
ments, growth  in  culture  media  is  less  rapid.  Above 
50  degrees  C.  (122  degrees  F.)  no  growth  occurs,  while 
at  the  pasteurizing  temperature  (60  to  65  degrees  C,  or 
140  to  160  degrees  F.)  practically  all  germs  are  killed 
even  with  an  exposure  of  a  few  minutes.  Boiling  is, 
of  course,  a  fortiori  fatal.  Milk  pasteurized  for  ten  or 
twenty  minutes,  or  water  brought  to  the  boiling-point, 
may  be  therefore  considered  as  practically  safe  from 
typhoid  infection. 

Typhoid  bacilli  grow  luxuriantly  in  laboratory  culture 
media  at  room  temperature  (20  degrees  C,  or  68  degrees 
F.).  At  lower  temperatures  their  growth  is  checked, 
but  is  not  entirely  stopped  even  near  the  freezing-point. 
Freezing  does  not  necessarily  destroy  bacterial  life, 
though  it  has  an  important  influence  on  longevity,  as 
elsewhere  mentioned. 

Food.  Like  other  bacteria,  the  typhoid  bacillus 
requires  a  food-supply  of  organic  and  mineral  matter, 
but  the  exact  nature  of  its  requirements  both  as  to 
quantity  and  quality  has  never  been  determined.  It  is 
known,  however,  that  so  small  an  amount  as  one  part 


46  TYPHOID    FEVER. 

of  organic  matter  in  a  million  parts  of  distilled  water 
will  materially  prolong  its  existence.  This  amount  of 
organic  matter  would  be  obtained  by  putting  about  one 
drop  of  milk  in  a  gallon  of  water. 

The  Longevity  of  the  Typhoid  Bacillus  in  Water. 

The  typhoid  bacillus  does  not  multiply  in  ordinary 
drinking-water,  even  though  the  water  be  polluted.  On 
the  contrary,  natural  water  is  an  unfavorable  medium, 
and  from  the  time  when  the  germs  enter  a  stream  or  a 
lake  or  a  well  or  the  salt  water  of  the  ocean,  there  is  a 
constant  dying  off  of  the  bacilli.  The  weaker  cells  die 
first,  and  there  is  generally  a  rapid  initial  reduction  in 
numbers,  due  perhaps  to  the  effect  of  plasmolysis,  that 
is, 'to  osmosis.  Later  the  decrease  is  less  rapid,  but 
continues  until  all  but  a  few  bacilli  have  disappeared: 
ultimately  all  the  cells  die.  This  is  the  present  con- 
ception of  sanitarians,  reached  after  a  great  amount  of 
experimentation  and  the  study  of  many  epidemics. 

Decrease  of  Typhoid  Bacilli  in  Water.  The  rate  at 
which  the  bacilli  decrease  in  water  varies  very  greatly, 
as  might  be  naturally  expected.  Laboratory  experi- 
ments are  far  from  being  in  perfect  agreement  on  this 
point.  In  some  of  the  experiments  almost  all  the  bacilli 
have  disappeared  at  the  end  of  three  to  five  days;  in 
others  ten  per  cent  have  lingered  for  a  month.  In  very 
cold  water  the  mortality  is  rather  more  rapid  than  in 
waters  at  summer  temperature;  in  waters  which  are  well 
oxygenated  it  is  less  rapid  than  in  stagnant  waters  deficient 
in  oxgyen;  in  waters  rich  in  organic  matter  the  longevity 


THE  TYPHOID  BACILLUS  AT  LARGE.  47 

is  greater  than  in  distilled  water,  but  in  nature  this  is 
more  than  offset  by  the  antagonistic  influence  of  the  more 
common  water  bacteria  and  of  other  organisms  higher 
in  the  scale  of  life. 

If,  for  the  purpose  of  illustration,  one  wished  to  use 
definite  figures  to  show  the  rate  of  decrease  of  typhoid 
fever  bacilli  in  ordinary  drinking-water  under  ordinary 
conditions,  it  might  be  said  that  after  a  week  the  water 
may  contain  30  per  cent  of  the  number  added,  after 
two  weeks  10  per  cent,  after  three  weeks  3  per  cent,  and 
after  a  month  or  six  weeks  i  per  cent  or  less.  A  fairer 
method  of  presentation,  however,  and  one  which  gives 
latitude  for  different  conditions,  is  shown  by  the  following 
diagram,  in  which  the  curve  illustrating  the  percentage 
decrease  in  number  would  fall  somewhere  within  the 
shaded  area.  Time  is  evidently  a  most  important 
element.  Age  does  as  much  for  water  as  it  does  for 
wine. 

The  Resistant  Minority.  It  will  be  noticed  that  the 
curve  in  Fig.  3  does  not  fall  quite  to  the  zero  line;  in 
other  words,  the  bacilli  do  not  wholly  disappear  within 
the  time  indicated.  This  brings  up  a  very  interesting 
point,  the  importance  of  which  is  gradually  impressing 
itself  oh  the  minds  of  bacteriologists.  In  almost  all  of 
the  recent  experiments  which  have  been  made  to  deter- 
mine the  longevity  of  typhoid  bacilli  exposed  to  unfavor- 
able influences,  such  as  heat,  cold,  freezing,  or  the  action 
of  various  disinfectants,  it  has  been  noticed  that  a  few 
individual  cells  seem  to  have  greater  powers  of  resist- 
ance than  the  general  mass  of  cells  in  the  culture.  For 
example,  occasionally  bacilli  may  be  found  alive  in  milk 


48 


TYPHOID    FEVER. 


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THE  TYPHOID   BACILLUS  AT  LARGE.  49 

after  heating,  or  in  ice  after  freezing,  or  in  water  to  which 
a  disinfectant  has  been  added:  and  whereas,  in  experi- 
ments with  drinking-water,  most  of  the  bacilli  disappear 
in  a  fortnight  or  a  month,  a  few  hardy  individuals  may 
persist  for  a  much  longer  period,  —  just  how  long  nobody 
knows.  Typhoid  bacilli  are  not  supposed  to  form 
spores,  and  what  makes  certain  cells  more  hardy  than 
their  neighbors  has  never  been  discovered;  in  fact, 
little  attempt  has  been  made  to  solve  the  problem. 
But  there  are  those  who  believe  that  many  of  the  unex- 
plained occurrences  of  typhoid  fever  might  be  made 
clear  if  we  had  a  better  understanding  of  the  longevity 
of  these  resistant  cells. 

In  considering  the  curve  shown  above,  where  99  per 
cent  of  the  bacteria  disappear  in  a  month  or  so,  there 
is  danger  of  focusing  the  attention  on  the  99  per  cent 
removed,  and  forgetting  the  i  per  cent  remaining.  It 
must  be  remembered  that  a  single  discharge  of  the 
bowels  of  a  typhoid  patient  may  contain  one  billion 
typhoid  bacilli,  —  perhaps  more  at  times,  —  and  that 
I  per  cent  of  one  billion  is  ten  million,  —  a  number 
of  bacilli  large  enough  to  do  immense  damage. 

It  must  be  remembered  also  that  the  conditions  under 
which  laboratory  experiments  are  necessarily  made  can- 
not perfectly  imitate  the  conditions  of  nature.  It  does 
not  do  to  rely  upon  them  too  implicitly.  On  the  other 
hand,  the  study  of  the  bacilli  in  nature  is  attended  with 
so  many  difficulties  that  results  from  such  observations 
also  have  to  be  received  with  caution.  Taking  them  at 
their  face  value,  however,  they  show  a  greater  longevity 
of  the  typhoid  bacillus  in  water  than  would  be  inferred 


50  TYPHOID    FEVER. 

from  the  experiments  made  in  small  receptacles  in  the 
laboratory. 

Some  German  investigators  once  isolated  an  organism 
which  they  believed  was  the  typhoid  bacillus  from  well 
water  several  weeks  after  infection,  and  one  observer 
isolated  the  germ  from  the  dead  end  of  a  distribution 
system  five  months  after  the  probable  date  of  infection, 
Hoffman,  experimenting  with  an  aquarium  in  which 
were  various  water  plants,  fish,  snails,  and  many  protozoa, 
and  which  was  exposed  to  sunlight  a  few  hours  each  day, 
recovered  the  typhoid  bacillus  from  the  water  after 
thirty-six  days,  and  from  the  mud  at  the  bottom  after 
two  months. 

Instead  of  casting  aside  such  observations  as  of  no 
value-,  it  is  worth  while  to  see  if  they  may  not  be  explained 
by  the  long  life  of  the  resistant  minority.  While  test- 
tube  studies  are  tending  to  show  a  short  life  of  the  typhoid 
bacillus  in  water,  observations  in  nature  seem  to  indi- 
cate that  some  of  the  bacilli  may  remain  alive  and 
virulent  for  many  weeks  and  months. 

Longevity  of  the  Typhoid  Bacillus  in  Sewage. 

The  early  experiments  showed  that  the  typhoid  bacillus 
had  a  greater  longevity  in  sterilized  water  than  in  water 
which  had  not  been  sterihzed.  Competition  with  other 
bacteria  was  apparently  not  favorable  to  a  long  life; 
but  whether  it  was  that  these  other  bacteria  robbed  the 
organism  of  its  food,  or  produced  substances  inimical  to 
its  growth,  was  not  made  clear.  The  difficulties  of  ex- 
perimentation were  great,  and  the  identification  of  a  few 
cells  of  B.  typhi   among  thousands  of  ordinary  sapro- 


THE  TYPHOID  BACILLUS  AT  LARGE.  51 

phytic  bacteria  was  so  difficult  that  the  negative  resuks 
obtained  from  the  unsterihzed  water  have  not  been  taken 
by  sanitarians  at  their  face  value. 

Decrease  of  Typhoid  Bacilli  in  Sewage.  But  recent 
experiments  made  with  greater  care  have  apparently 
corroborated  the  early  findings,  and  it  is  now  becoming 
recognized  that  the  typhoid  bacillus  has  a  shorter  life  in 
sewage,  which  teems  with  bacterial  life,  than  in  ordinary 
drinking-water.  By  putting  the  bacilli  into  a  sterile 
liquid  in  parchment  and  collodion  sacs,  and  suspending 
these  in  waters  of  different  degrees  of  pollution,  Jordan, 
Russel,  and  Zeit,  working  in  the  interest  of  the  Chicago 
Drainage  Canal,  attempted  to  simulate  natural  con- 
ditions and  at  the  same  time  to  avoid  the  old  difficulty 
of  trying  to  find  a  needle  in  a  haymow.  It  was  thought 
that  the  porous  membrane  would  permit  the  chemical 
substances  dissolved  in  the  sewage  and  the  products  of 
bacterial  growth  to  pass  into  the  sacs,  while  the  bacteria 
themselves  would  pass  neither  one  way  nor  the  other. 
Examining  the  bacterial  contents  of  the  sacs  from  time 
to  time,  it  was  found  that  the  typhoid  bacilli  lived  longest 
in  the  purest  water.  In  the  highly  polluted  water  of  the 
Chicago  Drainage  Canal,  they  apparently  disappeared  in 
from  one  to  three  days,  while  in  the  water  of  Lake  Michi- 
gan they  lived  from  four  to  eight  days.  These  experi- 
ments have  attracted  much  attention,  but  later  researches 
have  somewhat  discredited  the  technique  employed,  and 
the  figures  given  ought  not  to  be  taken  too  literally. 
Notwithstanding  their  possible  errors,  they  serve  well  to 
illustrate  the  general  fact  that  the  typhoid  fever  bacillus 
does  not  live  as  long  in  sewage  as  in  pure  water. 


52  TYPHOID    FEVER. 

There  are  a  number  of  reasons  why  this  is  so.  Sewage 
is  usually  devoid  of  oxgyen,  or  nearly  so,  and  experi- 
ments have  shown  that  oxygen  is  necessary  for  longevity. 
More  important,  however,  are  the  antagonistic  influences 
exerted  by  the  various  saprophytic  bacteria  which  are 
present  in  sewage  in  such  enormous  numbers. 

Fate  of  Typhoid  Bacilli  in  Cesspools.  If  the  con- 
clusions of  these  experiments  could  be  fully  trusted, 
typhoid-infected  sewage  that  has  remained  for  several 
weeks  in  a  cesspool  might  be  considered  as  innocuous, 
septic  sewage  might  be  less  feared  than  fresh  sewage,  and 
sewage  sludge  might  be  safely  used  on  gardens.  In 
this  matter,  however,  one  ought  not  to  lose  sight  of  the 
"resistant  minority."  The  danger  that  some  bacilli 
may"  remain  alive  in  sewage,  whether  in  a  septic  tank  or 
in  a  cesspool,  always  threatens,  and  the  only  safe  way 
to  deal  with  sewage  is  to  assume  that  it  is  always 
potentially  infective.  Furthermore,  there  are  the  records 
of  old  experiments  in  which  typhoid  bacilli  have  been 
found  to  live  months  and  even  years  in  fecal  matter, 
and  in  spite  of  all  their  shortcomings,  these  experiments 
cannot  be  safely  ignored. 

Efficiency  of  Sewage  Purification.  The  fate  of  the 
typhoid  bacillus  in  sewage  purification  works  has  been 
much  discussed  by  engineers.  Sedimentation  of  sewage 
in  tanks  generally  removes  two-thirds  of  all  of  the  bacteria 
in  the  raw  sewage,  chemical  precipitation  may  remove 
about  80  per  cent,  contact  beds  and  sprinkling  filters 
from  80  to  95  per  cent,  and  intermittent  filtration  through 
sand  from  95  to  99  per  cent.  It  may  be  fairly  assumed 
that  any  typhoid  bacilli  present  in  the  sewage  will  be 


THE  TYPHOID  BACILLUS  AT  LARGE.  53 

removed  in  amounts  which  are  at  least  equal  to  these, 
and  which,  by  reason  of  the  antagonism  of  the  sewage 
bacteria,  may  be  even  greater.  ]Most  sewage  purifica- 
tion works  are  not  intended  to  produce  an  effluent 
which  is  safe  to  drink,  but  rather  one  which  is  unob- 
jectionable from  the  standpoint  of  appearance  and  odor. 
Sewage  effluents,  therefore,  are  liable  to  retain  a  portion  of 
any  pathogenic  bacteria  present  in  the  raw  sewage,  and 
are,  accordingly,  dangerous.  It  is  only  by  some  subse- 
quent treatment,  such  as  disinfection  by  chemicals,  or 
purification  along  the  lines  of  water  filtration,  that  such 
effluents  can  be  rendered  innocuous.  To  render  sewage 
harmless,  is  by  no  means  impossible  of  attainment,  but 
it  demands  purification  works  of  a  high  order  of  effi- 
ciency, which  necessarily  involve  considerable  expense 
and  great  care  in  operation. 

The  Self-Purification   of  Streams. 

Intimately  involved  in  the  question  of  the  longevity 
of  the  typhoid  fever  bacillus  in  water  and  sewage,  is  the 
old  familiar  theory  of  the  self-purification  of  streams. 
Part  truth  and  part  error,  the  theory  that  "running  water 
purifies  itself"  has  lived  through  several  generations,  and 
still  has  a  strong  hold  on  the  public  mind.  As  its  mis- 
application may  do  much  harm,  it  deserves  more  than  a 
passing  notice. 

Of  a  pitcher  held  under  a  faucet,  it  may  be  truly  said 
that  it  is  filling,  yet  it  may  be  taken  away  without  its 
being  full.  And  with  equal  accuracy  it  may  be  said 
of  a  stream  that  it  is  purifying  itself,  while  at  the 
same  time  there  may  be  no  point  in  its  course  where  its 


54  TYPHOID    FEVER. 

waters  have  reached  what  may  be  fairly  termed  a  state  of 
purity. 

Streams  do  indeed  tend  to  become  better  in  quality 
as  they  flow  —  but  what  is  the  nature  of  the  betterment, 
and  what  is  its  extent?  All  depends  upon  the  answers 
to  these  questions.  There  are  a  good  many  factors 
involved  in  the  problem.  The  most  important,  so  far 
as  they  affect  the  bacterial  contents,  are  (i)  dilution,  (2) 
sedimentation  and  scour,  (3)  longevity  of  pathogenic 
bacteria,  (4)  sunhght,  (5)  aeration,  (6)  antagonism  of 
other  organisms. 

Effect  of  Dilution.  By  dilution  is  meant  the  attenu- 
ation of  the  substances  dissolved  in  water,  or  the  dis- 
persion of  bacteria  and  other  suspended  matter  through 
greater  volumes,  due  to  accessions  of  clearer  and  purer 
water  than  that  in  the  stream.  Streams  grow  in  size 
as  they  flow,  and  the  scattering  of  the  bacteria  through 
larger  masses  reduces  the  danger  from  drinking  the  water, 
even  though  no  real  purifying  agency  is  at  work.  In  a 
practical  sense,  therefore,  dilution  is  a  sort  of  purifica- 
tion; but  it  is  incomplete,  —  it  merely  minimizes  the 
danger  without  removing  it. 

Sedimentation.  In  most  streams  there  are  places 
where  the  current  is  slack  enough  to  allow  some  of  the 
bacteria  to  settle;  while  in  the  long  reaches  through 
meadows  and  swamps,  in  the  ponds  behind  mill-dams, 
and  in  quiet  pools  and  eddies,  a  river  tends  to  drop  its 
burden  of  suspended  matter,  and  the  flowing  water  be- 
comes purified  to  the  extent  of  these  depositions.  This 
is  a  true  purification,  as  many  of  the  bacteria  may  die 
after  subsidence;  but  it  is  only  a  partial  one.    The  periods 


THE  TYPHOID   BACILLUS  AT  LARGE.  55 

of  low  flow,  when  velocities  are  reduced  to  the  point  where 
sedimentation  occurs,  are  interrupted  by  floods  which 
scour  out  the  deposits  and  carry  them  farther  down 
stream,  thus  for  a  time  decreasing  the  purity  of  the 
water.  Sedimentation  and  scour  are  complementary 
forces;  one  purifies,  the  other  pollutes;  but  the  balance 
of  their  combined  effect  on  the  water  of  the  stream  is  a 
purifying  one. 

Time  the  Greatest  Factor.  The  natural  longevity  of 
the  typhoid  bacillus  in  water  has  already  been  mentioned, 
as  well  as  the  effect  of  sunlight  and  the  antagonistic 
influences  of  other  organisms.  It  has  been  said  above  that 
to  a  great  extent  longevity  is  a  function  of  time,  and  that 
the  danger  of  using  infected  water  gradually  lessens  as  the 
period  between  infection  and  use  increases.  In  the  self- 
purification  of  streams,  therefore,  it  is  not  a  question  of 
the  distance  that  a  river  flows,  but  rather  of  the  time  it 
takes  for  the  water  to  flow  from  one  place  to  another 
that  determines  the  extent  of  purification.  A  rapidly 
flowing  mountain  stream,  if  infected,  is  likely  to  carry 
its  infection  quicker  and  farther  than  a  slow  and  tortuous 
stream  flowing  through  a  plain. 

Aeration  and  Oxidation.  Aeration  counts  for  much  in 
the  self-purification  of  many  streams,  but  its  effect  on 
the  bacterial  contents  of  water  is  slight.  The  exposure 
of  water  to  the  air  as  it  falls  over  a  dam  or  ripples  down  a 
rocky  bed  tends  to  eliminate  any  odoriferous  gases  that 
may  be  dissolved,  and  to  restore  any  oxygen  that  may 
have  been  used  up  by  polluting  substances.  Aeration 
may  improve  the  taste  and  odor  of  water,  and  help  to 
oxidize  the  organic  matter  present,  but  it  does  not  destroy 


56  TYPHOID    FEVER. 

pathogenic  bacteria  in  appreciable  numbers;  in  fact, 
experiments  have  shown  that  typhoid  bacilU  live  longer 
in  water  which  contains  oxygen  than  in  water  which 
does  not.  The  vigorous  agitation  that  water  gets  in  a 
rapid  current  may  shake  the  life  out  of  some  weak 
cells,  but  its  influence  as  an  agency  of  purification  is 
insignificant.  The  author  once  fastened  a  bottle  of 
water  containing  typhoid  bacilli  to  the  piston-rod  of  an 
engine,  and  thus  it  was  shaken  vigorously  for  many  hours 
with  no  important  reduction  in  the  number  of  germs. 

Present  Status  of  Theory  of  Self-Purification.  The 
theory  of  the  self-purification  of  streams  has  had  many 
ups  and  downs.  Its  present  standing  among  sanitarians 
may  be  summed  up  as  follows:  Polluted  rivers  under 
natural  conditions  tend  to  become  pure.  The  improve- 
ment is  often  conspicuous  to  the  eye.  The  wholesome- 
ness  of  the  water  also  tends  to  improve,  but  not  to  as 
great  an  extent  as  its  improvement  in  appearance  would 
indicate.  Save  in  a  few  rare  instances  where  exceptional 
conditions  prevail,  the  natural  agencies  of  purification 
cannot  be  depended  upon  to  render  a  contaminated 
river  water  safe  for  drinking.  These  rare  instances  are 
where  the  contamination  is  originally  very  small  as  com- 
pared with  the  volume  of  the  stream,  or  where  the  time 
interval  is  very  long  and  the  various  other  purifying 
influences  exceptionally  potent. 

The  Self-Purification  of  Lakes  and  Reservoirs. 

The  same  natural  influences  that  tend  to  purify  run- 
ning streams  are  also  at  work  in  the  waters  of  lakes 
and  reservoirs,  and   in  most  cases  with  better  results. 


THE  TYPHOID   BACILLUS  AT   L.ARGE.  57 

This  is  so  far  true  that  an  eminent  sanitarian  has  said 
that  the  saying  that  "running  water  purifies  itself  " 
should  be  reversed  and  made  to  read  "standing  water 
purifies  itself." 

Dispersion,  When  sewage  is  allowed  to  flow  into  a 
lake  its  bacteria  gradually  become  dispersed,  or  diluted, 
by  the  action  of  horizontal  currents  induced  by  the  wind, 
and  by  vertical  currents  due  to  differences  in  temperature 
and  density  of  the  water  at  different  depths.  Dis- 
persion makes  the  water  less  and  less  likely  to  contain 
infection  as  its  distance  from  the  sewer  outfall  increases, 
and  thus  tends  to  reduce  the  danger  of  using  the  water, 
although  it  is  not  a  purification  in  the  strictest  sense. 

Sedimentation.  Sedimentation  is  usually  much  more 
potent  in  lakes  and  reservoirs  than  in  rivers,  and  the 
resulting  purification  is  correspondingly  greater,  while  the 
unfavorable  results  of  scour  are  less  likely  to  occur, 
especially  in  deep  lakes.  Wind  action  may  impart  move- 
ment to  the  water  near  the  surface  of  a  lake,  but  if  there 
is  any  considerable  depth,  the  water  in  the  lower  strata 
may  remain  comparatively  quiescent.  Shallow  lakes 
are  often  calm  for  short  periods  and  sometimes  for  long 
periods,  as,  for  instance,  when  they  are  frozen  over  in  the 
winter,  and  this  aff'ords  good  opportunities  for  subsidence. 
Deep  lakes  become  thermally  stratified,  and  the  water 
below  a  depth  of  twenty  or  thirty  feet  may  remain  practi- 
cally motionless  for  months  at  a  time.  The  summer  and 
winter  stagnation  of  lakes  has  many  important  bearings 
on  the  storage  of  water,  but  not  the  least  of  its  influences 
is  the  opportunity  that  it  gives  for  the  deposition  of 
suspended  matter  and  for  the  death  of  any  pathogenic 


58  TYPHOID    FEVER. 

bacteria  that  may  thus  settle  to  the  bottom.  The  chance 
of  scour  must  not  be  overlooked,  however,  even  in  a  lake. 
Wind  action  often  stirs  the  water  of  a  shallow  lake  to  its 
bottom;  while  between  the  times  of  summer  and  winter 
stagnation  in  a  deep  reservoir  there  are  periods  of  circu- 
lation when  the  water  at  the  bottom  rises  to  the  top 
and  some  of  the  accumulated  sediment  is  carried 
upwards. 

Beneficial  Influence  of  Storage.  The  long  storage  of 
water  in  a  lake  greatly  minimizes  the  danger  from  con- 
tamination. It  has  already  been  shown  how,  on  stand- 
ing, typhoid  fever  bacilli  decrease  in  numbers  in  natural 
waters,  and  how  after  a  month  a  body  of  water  may  con- 
tain only  a  few  per  cent  of  the  number  contained  at  first. 
The*  storage  in  large  lakes  often  amounts  to  many 
months. 

Antagonism  of  Microscopic  Organisms.  The  antago- 
nistic effect  of  other  organisms  is  greater  in  lakes  than  in 
streams.  The  waters  of  ponds  and  lakes  and  reservoirs 
frequently  contain  algal  and  protozoan  growths,  — 
often  to  such  an  extent  that  they  become  offensive  to 
sight  and  smell,  and  practically  unfit  for  use  as  a  water- 
supply.  The  "purging"  of  a  lake  is  a  common  phrase 
used  to  describe  these  growths.  It  is  popularly  supposed 
that  this  "purging"  is  a  natural  attempt  of  the  water 
to  purify  itself;  but  most  water  consumers  will  admit 
that  if  this  is  so,  Nature  has  adopted  a  very  crude  and 
unpleasant  method  of  securing  the  desired  result.  But 
there  is  more  truth  in  the  idea  of  purification  by  purging 
than  might  be  supposed.  The  algas  are  more  or  less 
gelatinous  in  character,  and  as  they  sweep  through  the 


THE  TYPHOID   BACILLUS  AT  LARGE.  59 

water,  driven  by  the  winds  and  currents,  they  entangle 
large  numbers  of  bacteria  and  destroy  them.  Some  of 
the  protozoa,  animal  in  nature,  actually  devour  the  bac- 
teria as  food.  It  is  a  fact  which  has  been  frequently 
noted,  that  algse  growths  tend  to  cleanse  the  water  of 
lakes  and  ponds  of  their  bacterial  contents.  This  ten- 
dency for  the  microscopic  organisms  to  destroy  typhoid 
bacilli  is  of  practical  importance  only  when  the  organisms 
are  present  in  large  numbers;  ordinarily  it  amounts  to 
very  little. 

Dangers  of  Depending  upon  Storage  Alone.  In  these 
various  ways  the  storage  of  water  in  lakes  and  reservoirs 
increases  its  safety  for  domestic  use.  Yet  one  should 
not  get  the  idea  that  storage  insures  complete  immunity. 
The  location  of  a  sewer  outfall  and  a  waterworks  intake 
in  a  lake  may  be  such  that  between  the  two  the  advan- 
tages of  storage  are  not  secured;  currents  may  carry 
pollution  from  one  to  the  other.  An  impounding  reser- 
voir may  have  a  stream  flowing  in  at  the  upper  end  and 
a  waterworks  gatehouse  at  the  lower  end;  this  reservoir 
may  provide  a  large  storage  and  act  as  an  important 
sanitary  safeguard  during  the  greater  part  of  the  year,, 
and  yet  at  times  of  large  stream  flow  it  may  permit  the 
water  to  flow  through  so  rapidly  that  the  storage  is  re- 
duced to  a  brief  interval,  with  consequent  danger  to  the 
water  consumers.  This  has  been  found  to  be  true  even 
in  reservoirs  of  very  large  size.  In  a  dry  season  also  the 
reservoir  may  be  almost  empty,  and  then  even  a  small 
rain  may  suffice  to  cause  the  water  to  flow  rapidly  across 
from  the  inlet  to  the  outlet. 

Unless  the   conditions  for  stream  purification  or  for 


6o  TYPHOID    FEVER. 

long  storage  in  large  reservoirs  are  very  exceptional, 
the  only  adequate  safeguard  against  a  polluted  drink- 
ing-water is  artificial  purification,  —  that  is,  filtration. 

Self-Purification  in  Conduits  and  Pipes. 

Some  of  the  discontaminating  influences  above  men- 
tioned continue  to  act  after  a  water  has  entered  the 
conduits  and  pipes  of  a  distribution  system;  namely,  sedi- 
mentation, the  natural  death  of  the  bacteria,  and  the 
antagonistic  influences  of  other  organisms.  If  the  water 
contains  many  microscopic  organisms,  that  is,  algae  and 
protozoa,  the  walls  of  the  aqueducts  and  the  interior  sur- 
faces of  the  pipes  may  become  coated  with  fresh  water 
sponge  or  with  "pipe  moss,"  a  fibrous  mass  of  animal  or- 
ganisms known  zoologically  as  the  Bryozoa.  These  bryo- 
zoa  consume  the  microscopic  organisms  as  food,  and  thus 
tend  to  reduce  the  number  of  bacteria.  The  chemical 
effect  of  the  iron  deposits  may  also  have  some  inhibiting 
effect  on  the  bacteria.  It  is  a  matter  of  common  obser- 
vation that  the  numbers  of  bacteria  in  water  decrease 
somewhat  in  passing  through  the  pipes  of  a  distribution 
system,  the  numbers  of  B.  coli  decrease,  and  presumably 
the  number  of  typhoid  bacilli  in  an  infected  water  would 
fall  off  in  the  same  way,  so  that  the  most  intense  infection 
would  be  likely  to  be  nearest  the  source  of  supply. 

Dead  Ends.  It  is  commonly  thought  that  the  "dead 
ends"  of  a  waterworks  system  are  the  frequent  cause  of 
disease.  They  do  occasionally  furnish  water  of  bad 
quality, — water  which  is  dirty  and  ill-smelling, — but  there 
is  little  or  no  evidence  that  such  water  is  the  cause  of 
typhoid  fever.     If  the  typhoid  fever  germ  is   affected 


THE  TYPHOID  BACILLUS  AT  LARGE.  6 1 

by  the  different  factors  in  the  manner  which  has  been 
described,  it  may  be  said  of  dead  ends  that,  so  far  as  this 
disease  is  concerned,  the  deader  they  are  the  better. 

As  a  rule,  the  purification  that  takes  place  in  the  pipes 
of  a  distribution  system  is  practically  negligible,  although 
it  is  of  some  theoretical  interest. 

Longevity  of  the  Typhoid  Bacillus  in  Ice. 

Laboratory  experiments  have  shown  that  in  a  general 
way  the  longevity  of  the  typhoid  bacillus  decreases 
gradually  as  the  freezing  temperature  is  reached;  that 
whereas  an  exposure  of  two  weeks  may  be  required  to 
reduce  the  number  of  typhoid  germs  by  90  per  cent  in 
water  at  70  degrees,  only  a  day  or  two  may  be  required 
if  the  temperature  of  the  water  is  at  o  degrees  or  near  it. 

In  ice  the  mortality  is  even  greater.  Sedgwick  and 
Winslow  have  shown  that  after  24  hours  the  reduction 
amounts  to  about  90  per  cent,  and  after  two  weeks  or 
more  to  99  per  cent.  Hence,  contaminated  ice  cut  in 
January,  may  be  used  in  July  with  only  one  per  cent  of 
the  chance  of  danger  that  would  be  run  by  using  the  ice 
when  freshly  cut. 

Natural  Ice.  Furthermore,  in  the  natural  process  of 
freezing,  it  has  been  found  that  about  90  per  cent  of  the 
bacteria  in  the  original  water  are  excluded,  or  frozen 
out;  that  is,  the  ice  which  forms  over  a  polluted  water  is 
only  10  per  cent  as  impure  as  the  v^^ater  itself.  The 
combined  effect  of  this  mechanical  elimination  of  im- 
purities by  freezing  and  the  death  of  the  bacteria  during 
storage  between  winter  and  summer  tends  to  reduce  the 
practical  danger  of  ice  infection  to  an  almost  negligible 


62  TYPHOID   FEVER. 

quantity,  provided  the  ice  is  properly  harvested  and 
stored. 

Unfortunately  this  is  not  always  the  case.  The  flood- 
ing of  ice  fields  by  making  holes  in  the  ice,  causes  the 
entire  body  of  flooded  water  to  be  frozen  into  the  cake, 
thus  eliminating  .the  natural  purification  by  exclusion. 
Such  flooded  ice  harvested  from  a  polluted  source  may 
be  very  objectionable.  Ice  from  a  shallow  water  may 
also  be  dangerous,  as  the  entire  body  of  water  may  freeze 
solid,  thus  rendering  the  bottom  ice  impure.  Fortunately 
these  errors  have  a  natural  corrective.  Flooded  ice  is 
often  dirty,  and  snow  ice  does  not  keep  well.  Large 
ice  harvesters  plane  off  the  dirty  ice  and  snow  ice.  If 
one  follows  the  practical  rule  of  never  using  in  the  house- 
hold ice  that  is  dirty,  the  danger  of  contracting  typhoid 
fever  from  it  may  be  substantially  eliminated. 

The  experiments  of  Sedgwick  and  Winslow  already 
alluded  to  showed  that  a  few  of  the  typhoid  bacilli 
experimented  with  had  a  power  of  resistance  much 
greater  than  the  general  average,  and  remained  alive 
for  a  number  of  weeks.  Prudden  and  other  observers 
have  also  noted  their  power  to  withstand  freezing.  The 
transmission  of  typhoid  fever  by  ice  through  these 
resistant  residual  cells  is,  therefore,  a  possibility  which 
ought  not  to  be  lost  sight  of;  and  while  the  author  believes 
that  it  rarely  occurs,  it  may  account  for  some  of  the 
cases  of  obscure  origin. 

Artificial  Ice.  It  is  natural  to  think  that  artificial  ice 
"made  from  distilled  water"  is  much  less  likely  to  be 
infected  than  natural  ice.  This,  however,  is  not  neces- 
sarily the   case.     From  the  foregoing  statements  it  is 


THE  TYPHOID   BACILLUS  AT  LARGE.  63 

seen  that  the  "time  element"  is  a  great  factor  in  making 
ice  safe  for  use.  In  the  case  of  natural  ice  element  this 
is  long;  in  the  case  of  artificial  ice  it  is  short.  The 
distilled  water  used  in  making  the  ice  may  be  pure,  but 
there  are  opportunities  for  the  receptacles  used  in  ice- 
making  to  be  contaminated.  The  author  knows  of  in- 
stances where  men  with  their  dirty  boots  walked  over  these 
receptacles  in  the  freezing  rooms,  and  where  privies 
have  been  located  almost  in  the  rooms  where  the  ice 
is  made.  Spring  waters  or  well  waters  are  often  used  in 
the  manufacture  of  ice,  and  these  may  be  subject  to  con- 
tamination. The  plants  for  manufacturing  ice  ought 
to  be  subject  to  rigid  inspection  on  the  part  of  the 
health  authorities. 

Handling  of  Ice.  Perhaps,  after  all,  the  greatest 
danger  from  ice  is  in  the  handling  during  distribution. 
It  is  walked  over  in  the  ice-houses,  peddled  through 
dusty  streets,  left  on  the  sidewalk  or  floor,  handled  by 
servants,  carted  around  in  railroad  stations,  and  dumped 
by  laborers  with  dirty  hands  directly  into  drinking-water 
tanks,  and  in  many  ways  subjected  to  chances  of  infection. 
Of  course,  the  outer  layers  of  ice  are  constantly  melting, 
and  this,  in  a  measure,  acts  as  a  natural  protection  from 
dirty  handling;  yet  some  danger  is  likely  to  remain. 

Longevity  of  the  Typhoid  Bacillus  in  the  Soil. 

The  life  of  the  typhoid  bacillus  when  buried  in  the 
soil  under  natural  conditions  is  probably  short.  This 
has  been  demonstrated  by  numerous  experiments,  al- 
though experiments  have  also  shown  that  in  sterile 
soils  the  germ  may  live  for  a  long  time.     The  soil  is  the 


64  TYPHOID    FEVER. 

great  repository  of  bacterial  life.  Garden  mold  is  teem- 
ing with  untold  myriads  of  bacteria  of  many  kinds — 
''soil  bacteria"  we  call  them.  They  serve  many  useful 
agricultural  functions,  and  among  these  the  production 
of  toxic  substances,  which  tend  to  destroy  such  patho- 
genic organisms  as  that  of  typhoid  fever,  is  not  the  least 
important.  Most  of  the  fundamental  instincts  of  man- 
kind have  a  scientific  foundation;  and  the  instinct  to 
bury  excrementitious  matter,  common  to  many  animals 
as  well  as  man,  is  no  exception  to  the  rule. 

It  is  because  of  this  action  of  the  soil  that  disposal  of 
the  stools  of  typhoid  fever  patients  by  burial  in  the  earth 
is  recommended.  It  is  the  soil  bacteria  near  the  sur- 
face of  the  ground  which  are  chiefly  responsible  for  the 
destruction  of  the  typhoid  bacilli;  hence  care  should  be 
taken  not  to  bury  the  stools  too  deep,  or  to  have  them 
too  concentrated.  It  is  not  sufficient  to  throw  them 
into  a  hole  dug  in  the  ground;  the  earth  should  be 
thrown  over  them.  A  new  hole  should  be  used  each 
time. 

Typhoid  bacilli  thrown  on  the  top  of  the  ground  are 
likely  to  survive  longer  than  if  buried,  but  between  dry- 
ing and  the  effect  of  sunlight  and  other  agencies,  they 
ultimately  succumb.  The  practice  of  throwing  the 
stools  and  urine  of  typhoid  patients  on  the  surface  of 
the  ground  is  highly  dangerous  on  account  of  the  possi- 
bility of  the  bacilli  being  washed  into  some  well  or 
watercourse,  or  of  being  picked  up  by  flies. 

This  destructive  action  of  the  soil  on  typhoid  germs 
must  not  be  depended  upon  too  implicitly,  and  care 
should  be  taken  that  burial  is  not  made  too  near  a  well 


THE  TYPHOID   BACILLUS  AT  LARGE.  65 

or  a  stream  used  for  drinking.  Dry  sandy  soils  contain 
few  soil  bacteria,  and  in  gravelly  soils  or  badly  cracked 
clay-beds,  percolation  may  take  place  rapidly  and  well 
water  contamination  may  result. 

Cesspools  usually  extend  into  the  ground  to  a  depth 
where  there  are  few  soil  bacteria.  Unless  made  water- 
tight, the  liquids,  with  more  or  less  suspended  matter, 
bacteria  included,  leach  away  into  the  ground.  In 
coarse,  porous  soil  these  germs  may  percolate  for  many 
feet,  possibly  to  pollute  some  water-supply,  as  elsewhere 
described.  Where  the  cesspool  is  old,  the  soil  around  it 
may  become  foul,  and  lose  some  of  its  natural  power  of 
purifying  the  leaching  sewage.  In  fine-grained  sandy 
soils,  however,  a  large  amount  of  natural  purification 
takes  place  around  a  cesspool. 

Longevity  of  the  Typhoid  Bacillus  in  Milk. 

The  behavior  of  the  typhoid  bacillus  in  milk  is  very 
different  from  what  it  is  in  water.  In  water  it  gradually 
dies  out;  in  fresh  milk,  on  the  contrary,  it  probably  mul- 
tiplies. At  least,  milk  is  a  favorable  culture  medium  for 
most  bacteria.  As  drawn  from  the  cow  it  contains  very 
few  bacteria  and  may  be  almost  sterile,  but  twenty-four 
hours'  standing  at  room  temperature  suffices  for  the  bac- 
teria present  to  develop  a  thousand-fold.  The  milk  sold 
in  most  of  our  cities  contains  anywhere  from  tens  of 
thousands  to  millions  in  each  teaspoonful.  It  may  be 
readily  imagined,  therefore,  that  milk  infected  with 
typhoid  fever  germs  may  be  highly  dangerous  by  the 
time  it  is  used. 

In  epidemics  due  to  milk,  the  suddenness  and  violence 


66  TYPHOID    FEVER. 

of  the  attacks  have  been  often  noticed,  —  indicating, 
apparently,  an  intense  infection. 

Of  the  bacteria  likely  to  be  found  in  milk,  the  lactic 
acid  bacteria  which  bring  about  the  souring  or  curdling, 
appear  to  thrive  most  luxuriantly.  Often  they  seem  to 
develop  to  such  an  extent  as  to  practically  subdue  all 
other  forms,  including  pathogenic  forms.  The  typhoid 
fever  bacillus  does  not  curdle  milk.  So  far  as  typhoid 
fever  is  concerned,  therefore,  sour  milk  is  not  more 
dangerous  than  sweet  milk;  it  may  be  even  less  so.  On 
the  other  hand,  milk  is  not  good  merely  because  it  is 
sweet. 

Experiments  appear  to  indicate  that  typhoid  fever 
bacilli  do  not  readily  multiply  in  milk  already  soured, 
that  is,  in  milk  which  contains  enormous  numbers,  of  the 
.lactic  acid  bacteria,  as  the  acid  or  some  other  antagonistic 
substance,  seems  to  inhibit  their  growth.  It  is  said  also 
that  they  do  not  grow  in  butter  or  cheese  for  similar 
reasons. 

The  viability  of  the  typhoid  bacillus  in  milk  needs  a 
far  more  careful  study  than  it  has  ever  received.  Our 
knowledge  of  its  fate  in  milk  is  not  nearly  as  extensive 
as  our  knowledge  of  its  fate  in  water. 

Longevity  of  the  Typhoid  Bacillus  in  Oysters. 

A  number  of  investigations  have  been  undertaken  to 
determine  the  longevity  of  the  typhoid  bacillus  in 
oysters,  but  most  of  the  tests  have  been  rather  unsatis- 
factory. Generally  speaking,  they  indicate  that  the 
bacillus  is  able  to  live  for  periods  ranging  from  a  few 
days  to  two  or  three  weeks.     Judging  from  some  of  the 


THE  TYPHOID  BACILLUS  AT  LARGE.     6-] 

experiments,  and  reasoning  by  analogy  from  other 
organisms,  there  is  reason  to  think  that  the  germs  do  not 
multiply  in  a  live  oyster,  but  that  they  may  grow  rapidly 
in  a  dead  one.  As  the  bloating  of  an  oyster  undoubtedly 
has  an  injurious  effect  upon  its  physiology,  it  may  be 
that  the  infection  of  a  bloated  oyster  is  a  more  serious 
matter  than  the  infection  of  one  of  natural  growth. 
The  experiments  indicate,  however,  that  the  longevity 
of  the  typhoid  germ  in  oysters  is  sufficient  to  more  than 
cover  the  interval  that  usually  elapses  between  the  gather- 
ing of  oysters  and  their  consumption. 

Longevity  of  the  Typhoid  Bacillus  in  Flies. 

Flies  may  transmit  the  typhoid  bacillus  in  two  ways: 
namely,  by  the  fecal  matter  containing  the  germ  adhering 
to  the  fly  and  being  mechanically  transported,  or  by  the 
fly  taking  the  germ  into  its  digestive  organs  and  depositing 
it  with  its  excrement.  An  interesting  illustration  of  the 
first  method  of  transmission  was  the  experiment  made  by 
someone  who  sprinkled  lime  in  a  privy  vault  and  exposed 
a  chocolate  frosted  cake  in  front  of  the  kitchen  window 
not  far  distant;  it  was  not  long  before  the  white  tracks  of 
the  flies  were  found  on  the  cake.  A  more  definite  experi- 
ment was  that  made  in  Chicago  where  flies  caught  in 
certain  privy  vaults  were  examined  and  found  to  contain 
B.  typhi. 

Some  experiments  have  been  conducted  to  ascertain 
the  duration  of  life  of  the  typhoid  bacillus  in  the  bodies 
of  flies  fed  on  infected  milk.  These  experiments  are 
not  wholly  satisfactory,  but  Fischer  states  that  he  found 
them  there  twenty-three  days  after  infection. 


68  TYPHOID    FEVER. 

Longevity  of  the   Typhoid  Bacillus  on  Fabrics. 

Although  typhoid  fever  is  not  conveyed  by  the  clothing, 
taking  this  expression  according  to  popular  usage,  yet 
the  clothing  of  a  typhoid  patient  may  become  infected 
and  the  infection  may  be  imparted  to  the  laundress  or 
to  some  comrade.  In  an  army  camp  or  in  the  close 
quarters  of  a  tenement  house,  this  may  be  an  important 
matter.  Firth  and  Horrocks  have  found  that  the  germs 
of  typhoid  fever  could  be  recovered  from  khaki  fabrics 
and  from  common  blue  serge  two  or  three  months  after 
infection. 


CHAPTER  V. 

LINES  OF  DEFENSE  AGAINST  THE  TYPHOID 
BACILLUS. 

A  WELL-PROTECTED  fort  has  more  than  one  line  of 
defense.  Besides  the  ramparts  behind  which  are  mounted 
the  disappearing  guns,  there  is  likely  to  be,  in  times  of 
war  at  least,  a  line  of  earthworks,  —  perhaps  more  than 
one,  —  and  beyond  that  various  outposts,  pickets  and 
scouts.  Within,  the  magazine  is  protected  against  fire  and 
against  stray  shots,  while  the  officers'  quarters  are 
guarded  by  sentries.  No  other  figure  so  well  describes 
the  precautions  which  must  be  taken  against  typhoid 
fever  and  diseases  of  its  type.  No  man  in  time  of  war 
can  alone  protect  himself.  Battle-ships  and  forts  are 
needed  to  keep  the  enemy  at  long  range;  but  once 
the  city  is  invaded,  the  individual  can,  in  a  measure, 
protect  his  own  hearthstone  and  the  members  of  his 
own  family. 

Cooperative  Work  Necessary.  Let  it  be  emphasized 
again  that  the  fight  against  disease  is  cooperative  work, 
and  that  just  as  the  public  authority,  the  household,  and 
the  individual  have  separate  parts  to  play  in  preventing 
the  germs  from  scattering,  so  also  they  have  separate 
functions  to  perform  in  defending  against  the  bacilli  at 
large.     These  three  lines   of  defense,    as  they  may  be 

69 


70  TYPHOID    FEVER. 

called,  are  illustrated  by  three  circles  in  the  diagram  in 
the  frontispiece.  The  largest  illustrates  the  work  of  the 
public  authorities,  the  health  department,  water  depart- 
ment, etc.,  which  affects  the  entire  community,  and 
which,  if  properly  done,  will  forestall  to  a  great  extent, 
but  never  completely,  the  necessity  for  the  inner  lines  of 
defense.  The  middle  circle  illustrates  the  care  that  must 
be  taken  by  each  household,  while  the  inner  circle  stands 
for  what  the  individual  can  do  in  the  way  of  self-pro- 
tection. 

First  Line  of  Defense. 

Public  Responsibility.  Continuing  our  figure,  it  may 
be  said  that  the  first  duty  of  a  board  of  health  is  to  spy 
out  the  enemy  and  give  warning  of  its  approach,  and  to 
act  as  a  bureau  of  information  on  the  prevalence  of  infec- 
tious diseases  in  the  community. 

In  most  states  there  are  laws  compelling  attending 
physicians  to  report  contagious  diseases  to  some  local 
health  authority,  but,  as  has  been  said,  these  laws  are 
almost  never  lived  up  to.  This  is  partly  due  to  careless- 
ness on  the  part  of  physicians,  and  partly  to  laxity  on  the 
part  of  the  authorities;  but  it  is  also  due  to  the  frequent 
uncertainty  of  the  physician  as  to  the  nature  of  the  dis- 
ease and  to  the  opportunities  for  criticism  that  would  arise 
in  case  of  error,  physicians  apparently  preferring  to  en- 
counter the  mild  impersonal  wrath  of  the  law  than  the 
personal  displeasure  of  the  patient  and  his  family.  It  is 
a  well-known  fact  that  during  an  epidemic  of  typhoid 
fever,  for  example,  the  ratio  of  reported  cases  to  deaths 
is  much  higher  than  when  there  is  no  epidemic,  —  often 


LINES  OF  DEFENSE.  7 1 

it  is  more  than  double,  —  showing  how  public  interest 
stimulates  the  physicians  to  their  sense  of  duty. 

Value  of  Statistics.  It  is  not  during  an  epidemic, 
however,  but  rather  before  the  epidemic  occurs  that  the 
reports  are  of  real  value.  Too  often  the  community 
realizes  that  disease  has  become  epidemic  before  the 
fact  is  reflected  in  the  health  department  records.  It 
may  even  happen  that  the  cases  may  be  reported  to  the 
authorities  and  yet  lie  idle  and  dormant  in  the  pigeon- 
hole of  some  negligent  clerk  until  they  are  routed  out  by 
a  newspaper  reporter  or  by  some  physician  or  citizen 
more  observing  than  others.  Morbidity  statistics  unless 
promptly  used  are  w^orthless.  It  is  not  enough  that 
they  be  accurately  and  properly  reported  and  recorded; 
they  must  be  constantly  under  observation  with  a  view 
to  the  immediate  detection  of  an  abnormal  increase. 
And  any  abnormal  increase,  no  matter  how  small,  should 
be  investigated,  as  one  can  never  tell  whether  it  may  not 
be  the  beginning  of  a  serious  epidemic.  Health  statistics 
are  too  often  treated  as  facts  for  history,  whereas  they 
ought  primarily  to  be  treated  as  facts  for  prophecy. 
Many  an  epidemic  might'  have  been  checked  half-way 
by  a  more  early  recognition  of  the  fact  that  there  was  an 
epidemic. 

Public  authorities  must  not  wait  for  epidemics  before 
establishing  their  lines  of  defense,  although  at  such  times 
the  lines  must  be  more  tightly  drawn.  There  are  certain 
routes  by  which  the  typhoid  germ  travels  that  must  be 
constantly  defended.  The  protection  of  the  purity  of 
the  public  water-supply,  the  protection  of  milk  and 
various  foods,  must  continually  be  maintained.     Some 


72  TYPHOID    FEVER. 

of  this  protective  work  has  already  been  alluded  to  in 
connection  with  the  three  barriers  against  the  scattering 
of  the  germs.  The  topics  which  require  special  mention 
here  are  the  purification  of  water,  the  certification  and 
pasteurization  of  milk,  and  the  safeguarding  of  other 
foods. 

Public  Water  Supplies.  If  a  public  authority  under- 
takes to  supply  a  city  or  town  with  drinking-water,  it 
would  seem  to  be  self-evident  that  upon  such  authority 
rests  the  responsibility  of  seeing  that  the  water  is  pure  and 
wholesome.  If  the  supply  is  furnished  by  a  private  water 
company,  it  would  seem  as  if  the  burden  of  protect- 
ing the  consumer  against  water-borne  diseases  should 
rest  with  the  company.  Yet  how  lightly  are  these  burdens 
borng !  In  how  many  cases  have  official  neglect  and  cor- 
porate greed  resulted  in  wide-spread  disaster!  In  how 
many  cases  has  the  failure  to  appreciate  the  besetting 
dangers  of  pollution  resulted  in  epidemics  of  appalhng 
magnitude!  In  how  many  cases  have  sanitary  reforms 
been  postponed  because  of  politics,  because  of  quarrels 
between  conflicting  interests,  because  of  failure  to  choose 
between  one  of  two  or  more  plans,  each  of  which  might 
have  brought  relief,  or  because  of  failure  to  appreciate 
the  public  danger! 

Not  long  ago  a  suit  was  brought  against  a  cer- 
tain western  city  to  recover  damages  because  of  the 
death  of  a  person  who  died  from  typhoid  fever,  caused, 
it  was  alleged,  by  the  infection  of  the  public  water- 
supply.  The  suit  was  lost.  There  are  some  who  be- 
lieve, however,  that  the  time  will  come  when  such  suits 
will  not  be  lost;  when  the  public  authorities  will  be  held 


LINES   OF  DEFENSE.  73 

legally  as  well  as  morally  responsible  for  deaths  due  to 
infected  water.  If  a  city  is  responsible  for  the  condition 
of  the  public  highways,  and  is  liable  in  case  an  injury 
results  from  neglect  of  proper  care,  how  much  greater 
the  responsibility  when  the  neglect  puts  in  jeopardy  the 
health  of  the  entire  community. 

Filtration  Increasing.  It  is  gratifying  to  see  that  so 
many  of  our  American  cities  have  awakened  to  the  need 
of  properly  safeguarding  the  quality  of  the  water  supplied 
to  the  public  for  drinking  purposes.  During  the  last 
five  years  filter  plants  have  been  built  and  put  in  opera- 
tion in  Charleston,  S.C.,  Youngstown,  Ohio,  Washington, 
D.C.,  Providence,  R.I.,  Xew  Haven,  Conn.,  Watertown, 
N.Y.,  Indianapolis,  Ind.,  Philadelphia,  Pa.,  Xew  ]\Iil- 
ford,  N.J.,  Brookhm,  N.Y.,  and  Binghamton,  N.Y., 
Little  Falls  and  Hackensack,  N.J.,  Chester,  Pa.,  and 
elsewhere.  Large  filters  are  under  construction  in 
Philadelphia,  Pittsburg,  Cincinnati,  Louisville,  Colum- 
bus, Ohio,  and  New  Orleans,  and  filter  plants  are  being 
enlarged  or  improved  in  Bangor,  ]Me.,  Albany,  X.Y., 
Yonkers.,  N.Y.  In  other  cities,  such  as  Troy,  New 
York  City,  Toledo,  Ohio,  Oakland,  Cal.,  Grand  Rapids, 
Mich.,  Wilmington,  Del.,  Minneapolis,  Minn.,  Trenton, 
N.J.,  L}Tin,  Mass.,  and  Lancaster,  Pa.,  they  have  been 
recommended,  and  projects  are  under  consideration. 
Chicago  has  spent  enormous  sums  to  divert  her  sewage 
out  of  Lake  Michigan.  Cleveland,  Buffalo,  and  Erie 
have  extended  their  intakes  farther  into  the  lakes. 
Oswego  is  preparing  to  do  so.  PoUuted  supplies  have 
been  abandoned  and  purer  sources  substituted  in  Newark, 
N.J.,  Jersey  City,  N.J.,  Augusta,  Me.,  Waterville,  Me., 


74  TYPHOID    FEVER. 

and  Hudson,  N.Y.,  while  renewed  attention  is  being  given 
to  the  ehmination  of  pollution  on  the  watershed  in 
Boston,  New  York,  and  Baltimore.  Many  other  cities 
might  be  named  in  each  group. 

Standards  of  Purity  Rising.  The  movement  to  secure 
pure  water  is  widespread.  Standards  of  purity  are 
becoming  higher.  Waters  that  ten  years  ago  would  have 
been  called  good  are  now  being  subjected  to  purification. 
Not  only  municipal  authorities  but  private  water  com- 
panies are  building  filters,  for  it  has  been  found  that  to 
sell  pure  water  pays  better  than  to  sell  impure  water. 
In  recent  appraisals  of  waterworks  properties  passing 
from  private  to  public  ownership,  the  award  has  been 
lowered  in  cases  where  the  water  was  polluted  by  an 
amount  approximately  equal  to  that  required  to  purify 
the  water  or  to  obtain  a  substitute  supply  of  good 
quality.  In  other  words,  depreciation  due  to  pollution 
has  been  recognized  by  the  courts. 

Safety  of  Ground  Waters.  In  view  of  the  strong  drift 
towards  filtration,  and  of  all  that  has  been  written  on  the 
relation  between  impure  water  and  the  public  health,  it  is 
not  necessary  to  discuss  this  subject  in  detail.  It  may 
be  said  in  passing,  however,  that  ground  waters  taken  by 
means  of  artesian  or  moderately  deep  driven  wells  are 
almost  invariably  safe  against  infection:  the  natural 
filtration  which  the  water  receives  in  the  ground  is 
almost  invariably  a  sufficient  protection.  Wells  in 
populous  districts,  where  the  soil  is  porous  or  fissured, 
as  in  limestone  regions,  may  become  dangerous  through 
underground  pollution. 

Dangers   from   Surface   Water.      Surface   waters   are 


LINES  OF  DEFENSE.  75 

safe  or  unsafe  according  to  the  population  on  their  water- 
sheds and  their  freedom  from  contamination,  and  in  pro- 
portion to  the  time  of  stream-flow  or  storage  between 
any  possible  sources  of  infection  and  the  city  mains. 
The  reason  why  the  stored  water  of  large  lakes  or  large 
reservoirs  is  safer  than  water  taken  direct  from  streams 
has  been  already  described.  Most  surface  waters  are 
open  to  accidental  contamination,  so  that  they  can  never 
be  considered  as  absolutely  safe,  even  though  the  popula- 
tion on  the  watershed  be  sparse. 

Sanitary  Supervision  of  Watersheds.  Much  can  be 
done  towards  making  surface  waters  safe  by  exercising 
a  sanitary  supervision  over  the  watershed,  eliminating 
all  direct  pollution  and  taking  all  possible  precautions 
against  accidental  contamination,  and  by  constantly 
keeping  watch  over  the  quality  of  the  water  by  the 
employment  of  inspectors  and  water  analysts.  In 
some  states  there  are  laws  against  the  direct  discharge 
of  sewage  or  fecal  matter  into  streams  used  as  water 
supplies.  In  others  there  are  laws  regulating  the  dis- 
tances within  which  privies  or  water-closets  may  be 
located  from  streams  and  reservoirs.  Some  cities  pre- 
serve the  quality  of  their  water-supplies  by  assuming 
the  duty  of  caring  for  the  privies  near  the  streams,  or 
by  contributing  to  the  expense  of  sewage  disposal  systems. 
It  has  been  suggested  that  cities  should  stand  the  expense, 
or  a  part  of  the  expense,  of  the  disinfection  of  sewage 
discharged  into  the  streams  tributary  to  its  water-supply. 
The  equity  in  these  matters  is  difficult  to  establish,  but 
it  is  likely  that  in  time  general  doctrines  based  on  the 
principles  of  the  common  law  will  become  recognized. 


^6  TYPHOID   FEVER. 

In  some  of  the  larger  cities  laboratories  for  water  analy- 
sis are  maintained  and  samples  analyzed  at  frequent 
intervals.  This  work  is  to  be  commended,  but  analyses 
should  not  be  regarded  as  a  fetich  or  allowed  to  take  the 
place  of  active  protective  work  on  the  watershed.  An 
individual  does  not  gain  in  weight  by  weighing  himself 
at  frequent  intervals;  and  analyses  should  be  used  as 
measures  of  the  protective  work  and  as  warnings  of 
sudden  dangers. 

Recognizing  that  it  is  infection  rather  than  contami- 
nation that  brings  real  danger,  some  water  departments 
make  arrangements  with  physicians  who  practice  among 
those  dwelling  on  watersheds  to  report  any  cases  of 
typhoid  fever  that  occur.  At  Waterbury,  Conn.,  the 
watershed  is  placa.rded  with  cloth  signs  stating  that  a 
reward  of  ten  dollars  will  be  paid  to  any  person  who 
first  informs  the  City  Engineer  or  Superintendent  of 
Water  Works  of  a  case  of  typhoid  fever  anywhere  on 
the  watershed.  Printed  postal  cards  addressed  to  the 
superintendent  are  furnished  to  all  physicians  in  towns 
bordering  upon  the  watersheds  with  the  request  that 
they  fill  in  the  blanks  and  mail  them  whenever  they  are 
called  to  a  case  of  intestinal  disease.  On  receipt  of 
such  a  card  the  city  undertakes  the  duty  and  stands  the 
expense  of  disinfecting  and  disposal  of  fecal  matter. 
A  somewhat  similar  system  is  in  vogue  in  Springfield, 
Mass.  The  reward  there  is  only  two  dollars  a  case, 
but  it  is  given  for  diarrheal  diseases  as  well  as  for 
typhoid  fever.  This  system  has  much  to  commend  it 
and  is  likely  to  increase  in  favor. 

'  These  facts  were  kindly  furnished  by  Mr.  R.  A.  Cairns,  City  Engineer. 


LINES   OF  DEFENSE.  "jy 

The  danger  of  all  such  methods  of  supervision,  how- 
ever, is  that  they  often  do  not  give  the  needed  informa- 
tion until  after  the  evil  has  been  accomplished. 

Effect  of  Filtration.  Filtration  affords  the  safest 
protection  of  surface  waters  against  water-borne  diseases. 
This  has  been  proved  by  long  experience  abroad,  and 
data  illustrating  this  truth  are  being  constantly  accumu- 
lated in  this  country.  In  Lawrence,  Mass.,  the  typhoid 
fever  death-rate,  after  the  city  filter  was  put  in  use,  fell 
from  an  average  of  121  to  an  average  of  26  per  100,000. 
After  the  construction  of  the  filter  in  Albany,  N.  Y.,  it 
fell  from  104  to  26;  in  Binghamton  from  49  to  11;  in 
Watertown,  N.  Y.,  from  97  to  27,  In  Philadelphia  the 
death-rate  has  greatly  decreased  in  those  sections  of 
the  city  where  the  filters  have  been  completed.  Numer- 
ous other  instances  are  cited  in  Chapter  X. 

There  are  two  principal  systems  of  water  filtration: 
sand  filtration,  that  is,  filtration  at  a  slow  rate  through 
beds  of  rather  fine  sand,  sometimes  acres  in  extent;  and 
mechanical  filtration,  which  consists  of  a  rapid  strain- 
ing of  the  water  through  coarser  sand  after  a  process 
of  chemical  coagulation.  Each  of  these  two  methods 
has  its  own  field  of  special  usefulness.  Each  is  able 
to  bring  about  a  satisfactory  degree  of  purification  if 
properly  carried  on.  Sand  filtration  is  especially  useful 
and  economical  for  clear  and  colorless  waters;  mechani- 
cal filtration  is  demanded  for  waters  which  are  either 
very  muddy  or  very  much  stained.  Sometimes  the  choice 
of  the  two  systems  is  merely  a  question  of  cost,  and  in 
most  cases  complicated  engineering  matters  are  involved. 
These  demand  the  services  of  an  expert.     Filters  pur- 


78  TYPHOID   FEVER 

chased  and  installed  as  one  buys  a  ready-made  machine 
are  almost  never  as  permanently  satisfactory  or  as  eco- 
nomical as  those  designed  by  a  competent  engineer  to  fit 
the  particular  local  needs. 

Vended  Waters.  In  many  cities,  especially  in  those 
where  the  public  water-supply  is  not  satisfactory,  the 
use  of  vended  spring  waters  is  very  common.  This 
practice  is  not  altogether  as  sanitary  as  most  people  sup- 
pose. Occasionally  the  much  advertised  spring  waters  are 
more  unsafe  than  the  public  water-supply,  while  too  often 
insufficient  care  is  given  to  the  receptacles  used  for  dis- 
tribution. In  some  cities  where  analyses  of  spring  waters 
have  been  made,  the  results  have  been  anything  but  sat- 
isfactory. It  would  be  unjust  to  condemn  all  vended 
waters,  as  most  of  them  are  probably  of  excellent  quality, 
but  the  matter  is  one  which  ought  to  be  carefully  looked 
after  by  the  health  authorities. 

Dangers  from  Dirty  Milk.  Milk  is  a  universal  food 
product,  and  one  which  enters  into  the  dietary  of  almost 
every  family.  Its  cleanliness  is  of  the  utmost  impor- 
tance. Dirty  milk  is  dangerous,  and  statistics  show  that 
it  is  a  most  important  vehicle  of  infection,  not  only  for 
typhoid-  fever,  but  for  many  diarrheal  troubles,  for 
scarlet  fever,  and  probably  for  other  diseases.  While 
the  sale  of  milk  is  almost  universally  in  private  hands, 
yet,  inasmuch  as  the  purchaser  in  a  large  city  is  power- 
less to  protect  himself,  the  supervision  of  the  milk  be- 
comes a  proper  function  of  the  board  of  health. 

Milk  may  become  infected  with  typhoid  fever  in 
various  ways.  The  hands  of  the  milker  may  convey  the 
infection,  the  milk  cans  may  be  washed  with  water  from  ■ 


LDsES    OF    DEFENSE.  79 

a  contaminated  well,  or  infected  water  may  be  added 
to  the  milk.  Handling  at  the  milk  depots  and  pouring 
from  can  to  can  offer  opportunities  for  the  introduction 
of  typhoid  germs,  and  the  passing  of  glass  bottles  from 
house  to  house  without  efficient  washing  and  steriliza- 
tion may  do  the  same.  The  glass  milk  jars  are  even 
taken  into  the  sick-room  by  the  poorer  classes,  who  find 
them  convenient  receptacles  for  daily  use  as  well  as  for 
transportation.  Physicians  have  reported  that  typhoid 
patients  have  even  been  seen  drinking  from  milk  jars. 

Certified  Milk.  Certified  milk  is  milk  derived  from 
farms  which  have  been  examined  by  some  authorized 
body  and  pronounced  satisfactory,  the  farms  being  kept 
continually  under  supervision  and  the  milk  being  regu- 
larly analyzed.  Certified  milk  is  sold  in  sealed  sterilized 
•glass  jars,  properly  labeled.  It  commands  a  higher 
price  than  ordinary  milk,  and  is  usually  worth  the 
money,  not  only  because  it  is  safer,  but  because  it  is 
richer. 

Inspected  Milk  is  a  grade  somewhat  less  carefully 
supervised  than  certified  milk,  but  better  than  ordinary 
milk. 

Pasteurized  Milk.  Pasteurized  milk  is  milk  that  has 
been  subjected  to  heat,  but  not  boiled.  The  temperature 
is  raised  to  160  degrees  F.,  or  thereabouts,  and  allowed  to 
remain  for  a  few  minutes,  after  which  the  milk  is  quickly 
cooled.  Pasteurization  effectually  destroys  the  typhoid 
germ,  as  well  as  most  other  germs  which  do  not  form 
spores.  It  is  therefore  a  safeguard  against  most^  milk- 
borne  diseases,  and  for  that  reason  is  strongly  advocated 
by  sanitarians.    That  the  general  use  of  pasteurized  milk 


80  TYPHOID    FEVER. 

would  materially  improve  the  health  of  our  cities  and 
greatly  reduce  the  number  of  deaths  of  young  children, 
is  evident  to  any  one  who  has  studied  the  results  already 
accomplished.  On  the  other  hand,  many  physiologists 
claim  that  pasteurized  milk  is  not  as  wholesome  as  raw 
milk,  and  is  less  easily  digested  and  advocate  the  super- 
vision of  the  sanitary  conditions  at  the  milk  farms  in  place 
of  general  pasteurization. 

That  pure  raw  milk  is  better  than  pasteurized  milk  will 
be  generally  admitted;  the  difficulty  is  in  making  certain 
that  the  raw  milk  is  pure.  Although  there  are  still 
differences  of  opinion  as  to  the  best  way  of  dealing  with 
the  milk  problem,  the  cause  of  pasteurization  seems  to  be 
steadily  gaining  ground.  Before  many  years  the  general 
pas'teurization  of  milk  in  large  cities  is  likely  to  be  as 
common  as  the  filtration  of  water. 

But  pasteurization  must  not  be  allowed  to  cover  the 
neglect  of  inspecting  the  farms  from  which  the  milk- 
supply  is  obtained.  In  many  states  and  cities  more 
stringent  laws  covering  the  sale  of  milk  are  urgently 
needed. 

Regulation  of  Oyster  Culture.  Oysters  naturally  grow 
in  pure  water.  Like  other  mollusks,  they  develop  from 
eggs.  Native  oyster  beds  are  usually  located  where  there 
is  a  rocky  bottom,  or  where  there  are  hard  substances 
to  which  the  "spat"  may  become  attached.  It  is  said 
that  natural  beds  furnish  about  half  of  the  oysters  used 
in  the  United  States;  the  remainder  comes  from  artificial 
beds  to  which  the  oysters  have  been  transplanted  in  order 
that  they  may  grow  to  better  advantage.  The  food  of 
oysters  consists  chiefly  of  diatoms  and  other  microscopic 


LINES    OF    DEFENSE.  8 1 

organisms  and  suspended  matter  found  floating  in  sea 
water;  and,  in  general,  the  larger  the  amount  of  this 
microscopic  life,  the  more  rapid  will  be  the  develop- 
ment of  the  oysters.  The  oyster  eats  by  taking  in  large 
volumes  of  water,  straining  out  the  organisms  as  the 
water  passes  through  the  gills.  Consequently  any 
bacteria  that  may  be  in  the  water  pass  in  a  continuous 
procession  in  and  through  the  oyster. 

In  order  to  supply  oysters  of  large  size,  it  Is  a  common 
custom  to  fatten  them,  or  float  them,  by  immersing 
them  in  brackish  water  before  they  are  sold;  and,  unfor- 
tunately, it  is  a  common  custom  to  carry  on  this  process 
in  localities  which  are  subject  to  sewage  pollution.  It  is 
chiefly  to  this  custom  of  "bloating,"  or  "plumping,"  or 
"floating"  oysters,  or  "letting  them  drink"  in  polluted 
water,  that  the  danger  of  infection  lies.  The  question  is 
often  asked,"  How  can  one  tell  whether  or  not  an  oyster 
has  been  floated?"  The  answer  is,  "It  cannot  be  told 
by  the  ordinary  consumer, "  and  not  always  by  an  expert. 
As  a  general  rule,  however,  small,  dark-colored  salt  oysters 
are  safer  than  large,  light-colored  fresh  oysters  which  are 
flabby  and  have  the  gills  and  the  muscles  swollen. 

The  viability  of  the  typhoid  bacillus  in  oysters  has  been 
already  referred  to,  and  on  subsequent  pages  references 
will  be  found  to  outbreaks  of  typhoid  fever  which  have 
been  due  to  the  use  of  infected  oysters.  Suffice  it  to  say 
here  that  the  practice  of  using  oysters  harvested  near  the 
mouths  of  sewers,  or  fattened  in  the  waters  of  streams  and 
harbors  subject  to  sewage  pollution,  is  attended  with 
real  danger  to  the  public  health. 

In  some   states,  as,  for  instance,  Massachusetts  and 


82  TYPHOID    FEVER. 

Connecticut,  laws  have  been  passed  restricting  the  culti- 
vation of  oysters,  and  similar  laws  are  under  considera- 
tion elsewhere.  The  matter  is  one  where  the  health 
authorities  should  assume  control.  In  some  localities 
the  sale  of  oysters  should  be  prohibited;  in  others  it  is 
probable  that  the  licensing  of  satisfactory  layings  would 
be  the  most  practicable  method.  It  is  possible  also  that 
some  plan  by  which  good  oysters  may  be  certified  in  the 
same  way  as  milk  is  now  certified  would  yield  favorable 
results,  and  be  a  benefit  not  only  to  the  public  but  also  to 
the  dealers. 

In  justice  to  the  oyster  dealers,  it  ought  to  be  stated 
that  they  are  beginning  to  appreciate  the  dangers  that 
may  come  from  infected  oysters,  and  many  market- 
men  refuse  to  handle  oysters  from  suspected  sources. 
If  the  oystermen  who  carry  on  the  business  of  floating 
their  product  in  polluted  waters  ought  to  be  forced  out  of 
the  market,  those  dealers  who  obtain  their  supply  from 
good  sources  ought  on  the  other  hand  to  be  encouraged. 
Oysters  are  an  important  article  of  food,  and  the  oyster 
industry  is  one  of  far  greater  magnitude  than  most  people 
appreciate,  —  amounting  in  value  to  nearly  one-third  of 
the  fishing  interests  of  the  country.  It  is  right  to  empha- 
size the  danger  from  oysters,  but  it  is  not  right  to  pro- 
duce a  general  "scare,"  for,  as  a  matter  of  fact,  oysters 
probably  cause  not  more  than  a  tiny  fraction  of  the 
typhoid  fever  of  the  country.  In  the  best  clubs  and 
hotels  nowadays  the  stewards  are  careful  where  they 
secure  their  supply  of  shell-fish. 

The  question  naturally  arises,  "Does  not  the  cooking 
of  oysters  destroy  any  germs  that  may  be  present?  " 


LINES    OF    DEFENSE.  83 

Numerous  experiments  have  been  made  to  answer  it, 
and  these  have  shown,  as  one  might  expect,  that  the 
application  of  heat  does  to  a  very  considerable  extent 
render  the  oysters  safe,  —  yet  not  completely  so.  The 
result  depends  upon  the  amount  of  heat  to  which  the 
oysters  are  subjected  and  the  time  of  exposure  to  this 
heat,  "Scalloped  "  oysters  are  exposed  to  a  rather  high 
heat  for  a  period  of  twenty  minutes  or  more,  and,  when 
thus  cooked  may  be  considered  as  quite  safe.  Fried 
oysters  are  also  raised  to  a  high  temperature  in  hot  fat, 
but  the  period  of  exposure  is  not  as  long.  Stewed 
oysters  or  oysters  cooked  in  "  fancy  roast  "  receive  still 
less  heat,  and  experiments  have  shown  that  often  the 
heating  is  not  sufficient  to  kill  all  the  bacteria  present. 
Consequently  oysters  from  polluted  sources  thus  cooked 
cannot  be  considered  as  wholly  free  from  danger. 
Steamed  clams  also  may  be  dangerous,  as  the  amount 
of  heat  to  which  they  are  subjected  is  comparatively 
small.  Lobsters,  on  the  other  hand,  require  consider- 
able heat  to  cook  them  properly,  and  consequently  any 
pathogenic  bacteria  that  may  be  present  are  quite  sure 
to  be  killed. 

Supervision  of  Food  Supplies.  Typhoid  fever  may  be 
transmitted  by  other  foods  than  milk  and  oysters.  A 
number  of  outbreaks  have  been  reported  in  various 
parts  of  the  country,  caused  by  the  use  of  infected  fruit 
and  vegetables.  There  seems  to  be  no  reason  why  a 
typhoid  patient  who  works  in  a  bake-shop  or  a  restaurant, 
or  who  otherwise  handles  food,  may  not  scatter  infection 
in  this  manner. 

These  vehicles  of  infection  are  so  numerous  that  it 


84  TYPHOID    FEVER. 

hardly  seems  practicable  to  establish  any  special  restric- 
tions in  regard  to  them.  What  should  be  done,  however, 
is  to  have  each  case  of  typhoid  fever  investigated  as  soon 
as  reported,  and  if  it  is  found  that  the  patient  has  been 
engaged  in  any  occupation  which  would  permit  of  the 
scattering  of  typhoid  fever  germs,  steps  should  be  taken 
to  stop  the  mischief  as  far  as  possible.  The  proper 
course  to  be  adopted  will  naturally  suggest  itself  in  each 
particular  case. 

Educational  Work  of  Boards  of  Health.  Not  the 
least  important  of  the  work  of  boards  of  health  is  the 
education  of  the  public  as  to  the  manner  by  which 
typhoid  fever  is  conveyed,  and  as  to  the  means  that 
should  be  adopted  to  prevent  infection.  Many  of  the 
state  and  local  boards  of  health  now  issue  weekly  or 
monthly  bulletins,  which  are  scattered  broadcast  to 
physicians  and  others.  Such  publications,  if  properly 
edited,  cannot  fail  to  be  beneficial  to  the  cause  of 
sanitary  science.  In  some  states  regular  conventions 
of  health  officers  are  held,  at  which  addresses  are  made 
by  experts  in  various  lines  of  work.  The  conferences 
of  the  health  officers  of  Vermont  and  New  York  may  be 
taken  as  models,  and  the  practice  is  one  worthy  of  being 
adopted  in  all  states.  The  interest  taken  in  sanitary 
matters  by  women's  clubs  and  civic  organizations, 
and  the  discussions  which  are  found  in  the  public  press, 
are  agencies  destined  to  have  a  widespread  influence. 
If  some  of  the  simple  sanitary  precautions  against  in- 
fectious diseases  were  taught  in  the  public  schools, 
it  would  do  more  to  improve  the  health  of  the  children 
than  any  amount  of  study  of  physiology  or  of  the  dangers 


LINES    OF   DEFENSE.  85 

from  the  use  of  alcoholic  liquors.  It  would  seem  proper 
even  to  carry  this  educational  campaign  into  the  churches, 
and  through  them  to  the  "submerged  tenth." 

The  Second  Line  of  Defense. 

Household  Responsibilities.  The  responsibilities  of 
the  household  in  warding  off  typhoid  fever  may  be 
summed  up  in  the  word  cleanliness,  —  clean  premises, 
clean  houses,  clean  water,  clean  food,  and  clean  persons. 

Many  of  the  things  which  the  board  of  health  does  on 
a  large  scale,  the  householder  must  do  on  a  small  scale. 
He  must  see  to  the  purity  of  the  well,  provide  screens  for 
the  house,  the  privy,  and  the  stable,  and  look  as  carefully 
as  circumstances  will  permit  to  the  source  of  foods  which 
are  used  uncooked. 

The  Country  Well.  Well  waters  are  generally  safer 
than  they  have  been  given  credit  for  in  sanitary  lit- 
erature, but  polluted  wells  are  very  numerous,  espe- 
cially in  thickly  settled  districts.  Most  wells  which  have 
been  the  cause  of  typhoid  outbreaks  have  been  contami- 
nated from  the  top;  that  is,  by  the  inflowing  of  polluting 
matters  over  the  curb.  Cases  where  outbreaks  of  disease 
have  been  due  to  infective  matter  passing  through  the 
soil  are  rare  except  where  the  soil  is  very  open,  or  where 
crevices  in  limestone  rock  or  clay  abound.  Sandy  soil  is  a 
good  filtering  material;  and  where  a  well  in  such  soil 
stands  at  the  center  of  a  circle  twenty-five  or  fifty  feet  in 
radius  within  which  there  are  no  privies,  cesspools,  sink- 
wastes,  or  other  sources  of  contamination,  the  water  can 
usually  be  depended  upon  as  being  fit  for  domestic  use, 
—  provided,  of  course,  that  the  top  of  the  well  is  properly 


86  TYPHOID    FEVER. 

guarded  against  surface  wash.  No  general  rule  governing 
the  permissible  relative  locations  of  well  and  cesspool  can 
be  given,  as  local  conditions  as  to  the  nature  of  the  soil, 
the  slope  of  the  ground,  the  level  of  the  underground 
water,  etc.,  must  be  taken  into  account.  In  case  of 
doubt  as  to  the  influences  of  a  cesspool  on  a  well,  it  is 
best  to  employ  a  bacteriologist  to  make  an  inspection  of 
the  site  and  take  a  sample  of  water  for  analysis.  In  some 
states  analyses  are  made,  on  request,  by  the  board  of 
health,  but  in  the  absence  of  data  regarding  the  surround- 
ings, such  analyses  cannot  be  properly  interpreted. 

Wells  should  be  cleaned  out  more  frequently  than  they 
usually  are.  Dust,  leaves,  pollen,  insects,  etc.,  all  con- 
tribute more  or  less  organic  matter  which  may  injure 
the  quality  of  the  water,  though  without  necessarily 
introducing  infectious  matter.  If  a  well  water  has  an 
unpleasant  odor,  it  is  almost  always  the  case  that 
the  well  needs  cleaning,  or  that  the  water  is  being 
contaminated. 

The  old-fashioned  well,  with  open  top  and  the  "  old 
oaken  bucket,"  is  unsatisfactory  on  hygienic  grounds. 

Boiling  the  Water.  If  the  public  water-supply  is 
open  to  suspicion,  the  householder  still  has  a  remedy. 
A  polluted  water  may  be  rendered  safe  by  boiling, 
and  this  is  the  best  course  to  adopt  in  case  danger  is 
feared.  Distillation  is  a  safe  but  troublesome  process. 
Boihng  for  five  or  ten  minutes  offers  the  best  protection, 
and  boiled  water  aerated  and  stored  in  bottles  in  the 
ice-chest  is  by  no  means  unpalatable. 

House  Filters.  House  filters  of  the  best  earthenware 
type  also  render  a  polluted  water  reasonably  safe.     A 


LINES    OF  DEFENSE.  87 

good  filter,  however,  is  expensive;  and  in  order  that 
purification  be  satisfactory  it  is  necessary  to  maintain  an 
inconveniently  slow  rate  of  filtration,  and  to  keep  the  filter 
scrupulously  clean.  Cheap  house  filters  of  the  sand  or 
charcoal  type,  and  even  good  filters  left  to  the  tender 
mercies  of  the  ordinary  servant,  are  worthless,  and  may 
do  more  harm  than  good. 

Pasteurization  of  Milk.  The  pasteurization  of  milk  in 
the  household  is  made  necessary  by  the  failure  of  the 
authorities  to  properly  safeguard  the  supply.  It  is  always 
a  wise  precaution  in  large  cities  during  hot  weather, 
when  the  difficulty  of  delivering  milk  of  satisfactory 
quality  is  greatest.  Whether  or  not  pasteurization  is 
advisable  at  all  times  is  still  an  open  question.  In  the 
case  of  some  children  cooked  milk  seems  to  cause  physio- 
logical disturbances  which  are  probably  quite  as  great  as 
those  due  to  the  use  of  milk  of  high  bacterial  contents. 
From  the  standpoint  of  infection,  however,  there  is  no 
doubt  as  to  the  merits  of  pasteurization. 

Screening  the  "Windows.  Effectual  screening  is  a 
sanitary  measure,  the  importance  of  which  is  being 
recognized  more  and  more  each  year.  Screens  are 
designed  to  keep  away  troublesome  insects,  such  as 
flies  and  mosquitoes.  The  history  of  screens  would 
make  an  interesting  story.  In  former  times  it  was  a 
common  custom  to  leave  the  houses  unscreened,  but  to 
use  little  hemispherical  screens  over  articles  of  food 
on  the  dining  table.  Some  restaurants  still  adhere  to 
this  method.  These  small  fly-guards  became  unneces- 
sary when  screens  began  to  be  used  on  the  doors  and 
windows  of  houses.     The  modern  theory  of  screening, 


88  TYPHOID    FEVER. 

is  to  put  the  bars  over  the  breeding-places  of  the 
insects,  —  over  privy  vaults  and  cellars  where  manure  is 
stored,  on  the  doors  and  windows  of  stables,  on  water- 
butts  and  other  breeding  places  of  mosquitoes. 

The  war  against  flies  is  a  reform  which  is  sure  to  be 
taken  up  in  earnest  before  many  years.  Thus  far 
the  housewife  has  striven  valiantly,  but  in  vain,  against 
a  host.  She  has  been  like  Mrs.  Partington  trying  to 
sweep  back  the  Atlantic  with  a  broom.  But  the  fight 
of  the  future  is  not  to  be  fought  by  the  housewife  with 
her  wire  brush  and  sticky  paper.  It  is  to  be  made 
against  the  breeding-places. 

The  task  is  not  so  hopeless  as  it  at  first  appears, 
especially  when  one  contemplates  the  work  done  at 
Panama  in  the  extermination  of  mosquitoes,  and  in 
Manchuria  during  the  Japanese-Russian  war  in  the 
elimination  of  flies. 

All  of  these  reforms  and  minor  sanitary  improvements 
necessary  to  eliminate  typhoid  fever  from  the  rural 
districts  will  be  very  slow,  and  difficult  to  secure,  — 
better  well  waters,  better  methods  of  sewage  disposal, 
better  constructed  privies,  greater  care  in  the  disposal 
of  cesspool  contents  and  sink-wastes,  better  methods  of 
handling  manure,  more  thorough  screening  of  houses, 
etc.  These  can  come  only  by  patient  popular  education. 
If  the  problems  of  the  city  are  more  difficult  than  those 
of  the  country,  they  are  also  more  fully  appreciated  and 
more  amenable  to  concerted  action.  The  problems 
of  the  city  are  to  be  solved  by  a  few  specialists;  those 
of  the  country  by  many  individual  laymen.  It  will  not 
be  long  before  the  cities  of  the  United  States  will  have 


LEsES    OF    DEFENSE.  89 

more  or  less  completely  removed  the  principal  causes  of 
typhoid  fever;  but  the  burden  of  the  rural  typhoid  must 
be  borne  by  country  doctors  and  town  officials  for 
many  years  to  come,  and  they  deserve  the  fullest  sup- 
port and  cooperation  on  the  part  of  the  general  health 
authorities.  The  sanitary  problems  of  the  farm  are  by 
no  means  trivial  or  unimportant  to  the  nation.  It  is 
"the  constant  dropping  that  wears  away  the  stone." 

Third  Line  of  Defense. 

Personal  Responsibility.  Finally,  what  can  the  indi- 
vidual do  to  protect  himself  from  typhoid  fever  ?  Really, 
very  little.  There  are  certain  precautions  that  can  be 
advised,  but  they  are  at  present  scarcely  more  than 
general  platitudes. 

The  Health  Tone.  ]\Iost  important,  probably,  is  the 
maintenance  of  a  good  "health  tone."  The  human 
mechanism,  when  it  is  in  perfect  physical  condition,  has 
powers  of  resistance  which  are  not  yet  fully  appreciated. 
A  lowering  of  the  health  tone  lessens  these  powers  of 
resistance.  Fatigue,  worry,  nervous  exhaustion,  indis- 
creet eating  and  drinking,  the  use  of  improperly  cooked 
or  impure  foods,  tend  to  derange  the  digestive  processes 
and  thereby  influence  the  secretions  poured  into  the 
intestinal  tract,  modify  the  bacterial  conditions  which 
exist  there,  and  make  it  easier  for  the  germs  of  typhoid 
fever  and  dysentery  to  gain  a  foothold.  This  subject  is 
still  shrouded  in  mystery,  but  each  new  research  seems 
to  strengthen  the  general  proposition  that  minute 
physiological  disturbances  may  be  the  indirect  cause  of 
serious  disease. 


90  TYPHOID   FE\'EIL 

One  way  in  which  the  fullest  advantage  may  be  taken 
of  the  protecting  influences  of  digestive  secretions  is  to 
---'->  water  or  milk.  :r  ei:  ::od  the  purity  of  which  is 
open  to  question,  at  the  ei.  I  : :  i  —  eal  rather  than  at  the 
begiiming,  or,  as  some  onr  Izi^  :i??tiously  stated  it, 
"  Never  eat  on  an  empty  stc  ~  i :  /.  7  h.e  reason  for  this 
is  that  during  digestion  :Jie  f ;~  ::  zistric  juice  is  in- 
creased; hence,  typhoii  zer-ii  :i2rT.  ir_:o  the  systein 
after  digestion  has  beg".:-"  5:1^1  ieii  ciiizie  of  mimina 
the  gauntlet  of  its  eneziie;  in  :i.e  E::~i;ii  ml  n^rer 
in:r -in-  than  at  tiie  beginning  ::  ::-:  meii.  "rien 
the  digesdve  faculties  are  Irmin:  n.e  ;er~  i-  n  :re 
likely  to  find  conditions  fi  :r^.ie  ::  ir  ri::nnen:. 
Although  httle  has  been  said  about  it  in  the  text-books^ 
aif d  although  it  has  not  been  scientifically  demonstrated, 
many  physiologists  apparently  believe  that  there  is  much 
truth  in  this  theory. 

Risks  of  Traveling.  The  individual  can  to  some 
extent  protect  himself  by  the  avoidance  of  known 
typhoid  fever  risks,  especially  when  traveling.  To 
drink  tiie  dty  water  at  the  present  time  in  Philadelphia 
or  HttsbuEg,  or  in  any  other  city  where  the  supply  is 
notoriously  polluted,  is  to  take  an  unwarranted  risk;  to 
eat  oysters  in  dieap  restaurants  in  New  York  or  Balti- 
—  :re.  where  the  supply  is  partly  derived  from  contam- 
ini:el  s'lrces,  is  also  a  risk;  to  drink  milk  at  an  ordi- 
nnr  resrn-irant  is  a  risk.  Many  traveling  men  have 
ccme  ::  jnierstand  these  dangers  and  to  avoid  them. 
Ti'e  ri:  i:e  i  -:raping  celery  before  eating  it;  of  re- 
m  inr  e  "  ei  :r'~  apples;  the  custom  of  washing  the 
iiinli    -e:::-r   i  niei...   and   other   matters  of   ordinary 


LEilS    :?    ZZ7Z2'SZ  91 


I—&C130SL. 


:^T)ei'  or  to  demanstri 


:ti  ::z    i_t  : jdjumaiy  way 

i.:r:-:L    is    ^— ^1-     Im 

r-^sidiQial  cdk  amril  about: 


CHAPTER  VI. 

TYPHOID    FEVER   STATISTICS. 

We  now  come  to  the  mathematics  of  typhoid  fever,  a 
subject  interesting  chiefly  to  the  speciaHst,  and  naturally 
considered  as  dry;  yet  to  one  who  takes  pains  to  under- 
stand the  statistics,  and  who  has  the  imagination  to  look 
beyond  the  figures  and  see  the  facts  for  which  they  stand, 
these  records  of  death  tell  a  wonderful  story.  They 
measure  the  steady  progress  of  sanitary  science  down  the 
years,  and  foreshadow  the  coming  of  the  day  when  the 
scourge  of  typhoid  fever  shall  be  all  but  swept  away; 
they  also  reveal  many  a  sad  case  of  official  ignorance  and 
carelessness,  and  many  an  instance,  besides,  of  patient 
and  unrewarded  public  service.  But,  if  the  records  of 
typhoid  epidemics  tell  a  story  of  shame  in  many  an 
American  city,  they  also  show  that  our  cities  are  learn- 
ing from  their  experiences,  and  that  almost  everywhere 
there  is  an  increasing  desire  to  provide  good  water,  good 
milk,  and  generally  improved  sanitary  conditions.  The 
statistics  afford  also  many  illustrations  of  cause  and  effect 
in  sanitary  matters,  and  demonstrate  in  striking  ways  the 
soundness  of  the  gospel  of  cleanliness.  The  histories  of 
typhoid  fever  epidemics  illustrate  the  brilliant  detective 
work  that  has  been  done  by  our  sanitary  experts,  and 

92 


TYPHOID    FEVER  STATISTICS.  93 

show  that  the  "bug  catcher"  has  come  to  be  a  most 
important  member  of  the  community. 

In  a  volume  of  this  size  it  is  impossible  to  give  more 
than  a  condensed  summary  of  typhoid  fever  statistics, 
to  describe  in  an  elementary  way  what  they  mean,  and  to 
guide  the  reader  where  to  look  and  what  to  look  for  in 
studying  the  subject  more  in  detail. 

Nature  of  the  Statistics.  Typhoid  fever  statistics  may 
be  considered  in  two  groups, — first,  those  which  appertain 
to  the  individual  case,  and,  second,  those  which  refer  to 
the  community,  the  second  being  practically  a  general  and 
condensed  summary  of  the  first.  The  unit  data,  show- 
ing when  and  where  a  patient  was  taken  sick,  and  all  the 
particulars  relating  to  an  individual  case,  are  necessary 
in  the  study  of  particular  epidemics,  but  they  are  of  less 
general  interest  than  the  summarized  statistics  of  the 
second  group. 

The  statistics  for  the  community  may  be  subdivided 
into  two  classes,  —  those  which  relate  to  sickness,  and 
those  which  relate  to  death;  that  is,  morbidity  statistics 
and  mortality  statistics.  For  reasons  already  pointed 
out,  the  morbidity  records  are  less  likely  to  be  accurate 
than  the  mortality  records,  the  law^s  regarding  the  filing 
of  death  certificates  being  much  better  lived  up  to  than 
those  requiring  physicians  to  report  their  typhoid  cases 
to  the  health  authorities.  Consequently  our  study  will 
concern  itself  chiefly  with  the  mortality  statistics. 

Death-rates.  One  of  the  terms  most  commonly  used 
in  sanitary  science  is  the  "death-rate."  By  this  is 
meant  the  ratio  which  the  number  of  deaths  in  a  com- 
munity in  a  given  time  bears  to  the  living  population. 


94  TYPHOID    FEVER. 

The  unit  of  time  is  generally  one  year,  while  the  unit  of 
population  is  taken  as  looo,  10,000,  or  100,000,  accord- 
ing to  custom  or  convenience.  To  illustrate  the  mean- 
ing of  "death-rate":  If  twenty  persons  should  die  in 
one  year  in  a  town  which  has  a  population  of  1000, 
the  annual  death-rate  would  be  said  to  be  "  20  per  1000"; 
if  thirty  persons  died  in  one  year  in  a  town  which  has  a 
population  of  1500,  the  annual  death-rate  would  again 
be  "20  per  1000";  —  in  other  words,  the  calculation 
of  the  death-rate  is  merely  one  of  simple  proportion. 
The  object  of  using  the  term  "death-rate"  is  to  enable 
one  to  compare  on  the  same  basis  the  sanitary  con- 
ditions in  communities  which  differ  in  population,  and 
in  the  same  community  at  different  times. 

When  the  term  "death-rate"  is  used  alone,  it  generally 
means  the  annual  ratio  of  deaths  from  all  causes  to  the 
living  population.  When  specific  diseases  are  in  question 
it  is  customary  to  speak  of  the  "  typhoid  fever  death-rate," 
the  "diphtheria  death-rate, "  etc.  General  death-rates  are 
usually  calculated  on  a  basis  of  1000  population,  as  the 
figures  thus  obtained  are  most  convenient  for  tabulation. 
Death-rates  for  particular  diseases  are  sometimes  cal- 
culated on  the  same  basis  or  on  the  basis  of  10,000,  but 
it  is  more  common  to  calculate  them  on  the  basis  of 
100,000  population,  as  this  tends  to  avoid  the  use  of  deci- 
mals, and  simplifies  tabulation.  Thus,  when  the  average 
annual  typhoid  fever  death-rate  for  the  United  States  is 
given  as  35,  it  means  that  of  every  100,000  of  the  popula- 
tion 35  persons  die  from  typhoid  fever  each  year.  All 
the  typhoid  fever  death-rates  referred  to  in  this  volume 
have  been  calculated  on  this  basis. 


TYPHOID   FEVER   STATISTICS.  95 

Monthly  death-rates  could  be  calculated  in  a  similar 
way,  by  finding  the  ratio  between  the  number  of  deaths 
in  the  month  and  the  living  population,  and  expressing 
the  result  as  so  many  per  1000,  or  10,000,  or  100,000. 
The  sum  of  the  monthly  death-rates  for  the  year  would 
thus  equal  the  annual  death-rate,  it  being  assumed  that 
the  population  does  not  change.  When,  however,  it  is 
desired  to  compare  the  mortality  in  any  month  with  the 
average  mortality,  the  monthly  death-rate  for  the  month 
in  question  is  multiplied  by  12,  so  as  to  show  what  the 
annual  death-rate  would  be  if  it  were  the  same  for  the 
whole  year  as  for  this  one  month.  This  method  is  more 
commonly  used,  perhaps,  than  the  other.  It  has  the 
advantage  of  maintaining  a  single  unit  of  comparison. 
Similarly  death-rates  may  be  calculated  for  weekly  periods, 
and  reduced  to  their  equivalent  annual  death-rates. 

It  will  be  seen  that  there  are  three  elements  involved 
in  the  calculation  of  typhoid  fever  death-rates,  —  first, 
the  number  of  persons  who  died  of  the  disease;  second, 
the  population  of  the  community;  and  third,  the  period 
of  time  during  which  the  deaths  occurred,  generally 
taken  as  one  year.  The  accuracy  of  the  death-rate 
depends,  therefore,  upon  the  correctness  of  the  number  of 
deaths  reported,  and  the  correctness  of  the  estimate  of 
population.  In  the  study  of  typhoid  statistics  it  is 
important  to  bear  this  fact  in  mind;  and,  as  both  quanti- 
ties are  likely  to  be  in  error,  too  much  attention  must  not 
be  given  to  very  slight  differences  in  calculated  death- 
rates. 

In  order  to  avoid  errors  due  to  incorrect  population 
returns,  the  typhoid  fever  statistics  are  often  figured  on 


96  TYPHOID    FEVER. 

the  basis  of  total  deaths;  that  is,  instead  of  calculating 
the  number  of  typhoid  deaths  per  100,000  population,  the 
rate  of  the  typhoid  deaths  to  100  deaths  from  all  causes 
is  found.  This  figure  may  be  termed  the  "percentage  of 
typhoid  fever."  The  method  is  useful  in  comparing  the 
relative  importance  of  different  diseases.  It  serves  as  a 
sort  of  check  on  the  death-rate. 

Figures  are  given  sometimes  to  show  the  fatality  of 
the  disease,  —  that  is,  the  rate  of  deaths  to  cases. 

To  illustrate  the  meaning  of  these  different  terms,  we 
may  assume  that  a  certain  community,  which  has  a 
population  of  20,000,  had  in  one  year  400  deaths  from 
all  causes,  15  deaths  from  typhoid,  and  250  cases  of 
typhoid;  then: 

The  total  death-rate  would  be  20  per  1000; 
The  typhoid  fever  death-rate,  75  per  100,000; 
The  percentage  of  typhoid  fever,  3.75  per  cent,  and 
The  fatality  of  typhoid  fever,  6  per  cent. 

Sources  of  Error.  One  of  the  most  important  sources 
of  error  in  typhoid  statistics  is  the  faulty  diagnosis  of  the 
disease.  The  experience  of  the  Spanish  war  taught 
that  many  so-called  cases  of  malaria  were  really  typhoid 
fever,  while  probably  some  cases  were  called  typhoid 
fever  that  were  really  due  to  improper  diet.  Dr.  Ful- 
ton, of  Baltimore,  has  shown  that  this  is  true  to-day  of 
much  of  the  malaria  in  the  southern  states.  The  cases 
are  much  fewer,  however,  where  true  malaria  is  diagnosed 
as  typhoid  fever.  In  the  past,  when  diagnosis  was  based 
wholly  on  symptoms,  there  was  some  excuse  for  the  con- 
founding of  these  two  diseases;  but  now  that  we  have 


TYPHOID   FEVER  STATISTICS.  97 

the  bacteriological  tests  for  typhoid  fever,  and  can  detect 
the  malarial  parasite  in  the  blood  by  microscopical 
examination,  such  errors  are  in  most  cases  inexcusable. 
As  a  matter  of  fact,  there  has  been  a  decided  improve- 
ment in  diagnosis  in  recent  years.  The  tendency  of  this 
more  exact  diagnosis  has  been  to  increase  the  amount 
of  typhoid  fever  given  in  the  statistics;  and  this  fact  must 
be  borne  in  mind  in  making  chronological  comparison, 
and  in  comparing  the  typhoid  fever  death-rates  in 
malarial  and  non-malarial  regions. 

Another  source  of  error  in  the  statistics  is  due  to  the 
confusion  resulting  from  complications  in  the  disease. 
It  was  said  above  that  less  than  half  of  the  typhoid 
patients  who  die,  succumb  from  the  direct  effects  of  the 
disease;  more  die  from  the  effect  of  the  comphcating,  or 
secondary  diseases.  Thus,  a  person  may  get  typhoid 
fever,  and  before  this  disease  has  run  its  course  pneu- 
monia may  set  in,  and  the  patient  may  die  from  the  latter 
cause.  The  physician  should,  of  course,  report  this 
as  a  case  of  typhoid  fever;  but  he  may  report  the  death 
as  due  to  typhoid  fever  or  to  pneumonia,  or  he  may  call 
it,  as  he  often  does,  typhoid-pneumonia.  Sanitarians 
are  at  variance  as  to  the  proper  course  to  be  pursued  in 
this  case.  If  the  pneumonia  was  due  to  an  invasion  of 
the  lungs  by  the  typhoid  bacillus,  the  death  should 
unquestionably  be  reported  as  typhoid  fever;  but  if  the 
pneumonia  was  due  to  the  pneumococcus,  there  is  more 
reason  for  calling  it  pneumonia,  and  whether  it  were 
called  typhoid  fever  or  pneumonia  would  probably  be 
determined  in  the  mind  of  the  physician  by  the  time 
that  elapsed  before  the  secondary  infection  took  place. 


98  TYPHOID    FEVER. 

It  would  appear  to  be  logical  to  report  such  a  case  as 
typhoid-pneumonia,  or  typho-pneumonia;  but  this  term 
has  been  so  much  abused,  and  has  been  so  much  used 
to  describe  severe  cases  of  pneumonia  where  there  was  no 
typhoid  infection  at  all,  that  sanitarians  are  now  almost 
unanimous  in  condemning  the  use  of  the  double  term. 
Physicians  are  sometimes  too  explicit  in  reporting 
causes  of  death.  For  example,  a  lady  in  Maine,  accord- 
ing to  an  old  record  in  a  city  clerk's  office,  is  said  to 
have  died  from  "typhoid  fever,  bronchitis,  pneumonia, 
and  a  miscarriage."  From  the  standpoint  of  epidemiol- 
ogy, it  would  be  preferable  to  classify  cases  according  to 
the  first  infection;  but  as  the  vital  statistics  are  not  to  be 
used  alone  for  a  study  of  epidemics,  there  is  some  objec- 
tion to  this  course.  In  important  investigations  it  is 
always  advisable  to  refer  back  to  the  original  death 
certificates.  Greater  uniformity  is  desired  in  these 
•matters,  and  the  uncertainties  are  here  mentioned  merely 
to  warn  the  reader  to  be  on  his  guard  in  studying  typhoid 
statistics,  and  not  to  give  too  much  weight  to  published 
records.  There  has  been  recently  organized  in  the 
American  Public  Health  Association,  a  Section  of  Vital 
Statistics  for  the  purpose  of  considering  all  questions 
relating  to  this  subject. 

TJie  old  records  of  typhoid  fever  in  many  places  are 
liable  to  be  in  error  by  reason  of  incompleteness,  and  in 
studying  the  statistics  it  is  wise  to  take  into  account  the 
date  when  adequate  registration  laws  were  put  in  force. 

In  generalized  statistics  minor  errors  became  less 
prominent,  so  that  in  spite  of  all  the  inaccuracies  which 
the  typhoid  fever  records  of  the  country  contain,  they 


TYPHOID   FEVER  STATISTICS.  99 

are  sufficiently  exact  to  show  the  main  facts  in  regard  to 
the  relative  abundance  of  the  disease  in  different  places 
and  at  different  times. 

Morbidity  Statistics.  The  incompleteness  of  morbidity 
statistics  of  typhoid  fever  based  on  physicians'  reports, 
is  usually  so  great  as  to  make  them  practically  useless. 
A  few  examples  will  suffice  to  illustrate  this : 

In  Brooklyn,  N.Y.,  in  1904  there  were  1050  reported 
cases  of  typhoid  fever  and  303  deaths,  indicating  a 
fatality  of  29  per  cent;  in  New  York  City  (borough  of 
Manhattan)  in  the  same  year  there  were  2136  cases  and 
309  deaths,  indicating  a  fatality  of  14.5  per  cent.  When 
complete  statistics  are  obtained,  the  percentage  fatality 
in  typhoid  fever  almost  never  exceeds  10  per  cent.  In 
Waterville  and  Augusta,  Me.,  where  in  1902-3  statistics 
were  obtained  by  a  house-to-house  canvass,  the  fatality 
was  8.6  per  cent;  in  Ithaca  in  1903  it  was  6.1  per  cent; 
in  the  United  States  military  camps  during  the  Spanish 
war  it  was  7.6.  The  fatality  varies  according  to  age,  as 
referred  to  elsewhere. 

When  an  epidemic  occurs,  physicians  are  more  likely 
to  report  cases  of  typhoid  fever  than  at  other  times  when 
there  is  no  excitement.  Thus,  in  Cleveland,  the  ratio  of 
typhoid  deaths  to  reported  cases  in  1902  was  27  per 
cent;  during  the  epidemic  years  of  1903-4  it  was  14.5 
per  cent;  in  1905,  after  the  excitement  had  subsided,  it 
rose  to  ^^  per  cent.  It  is  not  infrequent  that  health 
department  records  will  show  a  larger  number  of  deaths 
from  typhoid  fever  than  there  were  cases  reported. 

For  this  reason,  in  the  study  of  epidemics  it  is  necessary 
to  take  special  steps  to  secure  accurate  data. 


lOO  TYPHOID    FEVER. 

Sources  of  Information.  Those  who  desire  to  know 
the  typhoid  fever  situation  in  their  own  town  or  city  or 
state,  should  consult  the  reports  of  the  local  board  of 
health  or  the  reports  of  the  state  board  of  health,  if 
they  are  published;  and  if  they  are  not,  they  should  then 
seek  the  original  authorities,  by  going  to  the  officials 
charged  with  keeping  the  records  of  death  certificates. 
The  United  States  Bureau  of  the  Census  published  in 
1900  a  rather  complete  series  of  statistics  for  that  year 
for  a  portion  of  the  United  States  known  as  the  "regis- 
tration area,"  and  the  same  bureau  now  publishes 
annually  the  typhoid  fever  death-rates  for  the  principal 
cities  of  the  country.  These  data  are  issued  in  the  form 
of  bulletins,  which  can  be  obtained  by  writing  to  the 
Director  of  the  Census,  Washington,  D.C.  From  the 
same  source  can  also  be  obtained  a  table  of  the  esti- 
mated populations  of  the  principal  cities  for  each  year 
since  the  last  census. 

For  the  convenience  of  the  reader,  there  is  given  in 
Appendix  X  a  table  of  typhoid  fever  death-rates  for  the 
principal  cities  of  the  country  for  each  year  since  1898, 
compiled  from  the  records  of  the  Census  Bureau  and 
the  Bureau  of  Labor.  Comparison  of  these  figures 
with  those  obtained  from  local  sources  do  not  always 
show  an  exact  agreement,  yet  for  the  most  part  the 
figures  may  be  taken  as  substantially  correct.  There  is 
also  a  table  giving  the  number  of  deaths  in  the  larger 
cities  of  the  country  for  a  longer  term  of  years,  and  still 
other  tables  for  certain  cities  where  the  data  are  of 
especial  interest. 

It  is  common  to  compare  death-rates  by  the  use  of 


DISTRIBUTION   OF  TYPHOID    FEVER. 


lOI 


NOaVTOdOd 


H3A3d  QIOHdAX  WOaS  SHXVBQ  dO  UaakMON 


Fig.  4. 


Diagram  Showing  the  Xumber  of  Typhoid  Fever  Deaths  and  the  Corre- 
sponding Death-rates  in  St.  Louis,  Mo. 


I02  TYPHOID   FEVER   STATISTICS. 

diagrams.  These  are  usually  simple  and  self-explana- 
tory. A  very  convenient  form,  but  one  little  used,  is 
shown  on  page  loi.  Here  the  population,  the  number 
of  deaths,  and  the  death-rate  are  given  on  the  same 
diagram.  The  first  two  are  read  from  the  horizontal 
lines,  the  reference  numbers  being  on  the  left  and  right 
of  the  diagrams;  the  third  is  read  by  using  the  inclined 
lines  upon  which  the  reference  figures  are  marked  and 
noting  the  relation  of  the  broken  profile  to  these  lines. 


CHAPTER  VIL 
DISTRIBUTION   OF   TYPHOID    FEVER. 

It  will  be  of  interest  to  consider  briefly  what  the  statis- 
tics show  as  to  the  distribution  of  typhoid  fever  among 
persons  of  different  age,  sex,  race,  occupation,  etc., 
and  the  variations  in  the  death-rates  in  different  parts 
of  the  country.  These  topics  cannot  be  discussed  in 
detail,  but  the  figures  given  are  sufficient  to  show  what 
are  the  main  factors  concerned  in  the  distribution  of  this 
disease. 

Age  Distribution.  Typhoid  fever  is  essentially  a 
disease  of  youth  and  middle  age.  Deaths  from  it  are 
comparatively  rare  in  childhood  and  in  old  age.  At 
the  time  of  the  last  United  States  census,  in  1900,  it 
was  found  that  more  than  one-third  of  the  deaths  from 
typhoid  fever  occurred  among  persons  between  15  and 
30  years  of  age;  only  10  per  cent  among  children  under 
5  years  of  age,  and  10  per  cent  among  persons  over  50 
years  of  age.  These  are  average  figures,  and  do  not  hold 
at  all  times  for  every  community.  Thus,  in  a  city  where 
the  drinking-water  of  a  school  has  been  contaminated,  or 
where  there  has  been  an  epidemic  caused  by  milk,  the 
proportion  of  deaths  may  be  especially  high  among  the 
children. 

103 


104 


TYPHOID    FEVER. 


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DISTRIBUTION   OF  TYPHOID   FEVER. 


105 


It  is  generally  taken  for  granted  that  the  figures  which 
show  the  age  distribution  of  typhoid  fever  mean  that 
people  are  more  susceptible  to  the  disease  in  middle 
life  than  in  youth  or  old  age.  This,  however,  is  not  a 
true  explanation.  A  better  reason  would  be  that  per- 
sons in  middle  life  are  subjected  to  greater  exposure. 
In  the  first  place  it  should  be  noted  that  the  figures  in 
the  seventh  column  of  the  table  on  page  104  show  a  too 
great  disparity  between  persons  of  different  age,  for  the 
reason  that  they  take  no  account  of  the  age  distribution 
of  the  population.  It  is  fairer,  therefore,  to  consider  the 
age  distribution  of  typhoid  fever  on  the  basis  of  death- 
rates  per  100,000  persons  of  the  specified  age,  as  is  done 
in  the  last  column.  From  this  it  will  be  seen  that  the 
death-rate  in  middle  life  is  only  about  twice  what  it  is  in 
old  age,  and  only  about  three  times  what  it  is  in  childhood. 


Age  Groups. 


Under  5  years  . 

5  to  10   .    .    .  . 

10  to  15   .    .    .  . 

15  to  25   .    .    .  . 

25  to  35    .    .    .  . 

35  to  45   •    •    •  • 
45  and  upwards 

Total    .    .  . 


Number  of 
Persons 
Attacked. 


84 
154 
161 
281 
169 

91 


1008 


Num- 
ber of 
Deaths. 


5 
13 
32 
26 

17 
24 


119 


Ratio  of 

Percentage  Number  of 
Fatality.       Cases  to 
Deatlis. 


II. 81 


38 

42 

25 

30 

07 

12 

35 

8 

3« 

6 

68 

5 

29 

2 

A  study  of  the  relative  fatality  of  the  disease  at  different 
ages  also  tends  to  show  that  the  middle-age  maximum  as 
ordinarily  stated  is  too   much  exaggerated.     The  per- 


I06  TYPHOID    FEVER. 

centage  of  children  who  recover  from  the  disease  is  far 
greater  than  in  the  case  of  older  people.  This  is  well 
shown  by  the  figures  on  page  105  taken  from  Dr.  Reece's 
report  on  the  epidemic  which  occurred  in  Lincoln, 
England,  in  1905.  It  will  be  seen  that  in  this  case  the 
fatality  of  the  disease  increased  almost  directly  with  the 
age. 

Now,  if  an  accurate  and  extended  series  of  figures  of 
this  character  could  be  obtained  for  a  very  large  number 
of  cases,  and  applied  to  an  equally  accurate  and  extended 
table  showing  the  death-rates  at  different  ages,  it  seems 
probable  that  the  calculated  rate  per  100,000  of  persons 
attacked  at  the  different  ages  would  be  greatest  in  child- 
hood and  decrease  toward  old  age.  Unfortunately,  the 
data  for  an  exact  calculation  are  not  now  at  hand. 

Fig.  5  shows  diagrammatically  some  of  these  facts 
regarding  age  distribution.  The  lines  for  percent- 
age fatality  and  case-rate  (rate  of  attack)  are  based  on 
inadequate  data  and  are  to  be  regarded  merely  as 
illustrative.  A  further  study  of  this  subject  would 
prove  very  instructive. 

The  fact  that  so  few  children  die  of  typhoid  fever, 
then,  does  not  show  that  the  disease  is  not  acquired  at 
that  age.  There  are  doubtless  many  more  "walking 
cases"  among  children  than  among  adults.  This  helps 
to  explain  why  children  are  such  an  important  factor 
in  the  spread  of  the  disease. 

Infants  and  very  young  children  are  in  general  less 
exposed  to  typhoid  infection  than  persons  in  middle  life; 
their  diet  is  much  simpler,  and  their  environment  is 
more    limited.     Yet    typhoid   fever    is    by  no    means 


DISTRIBUTION    OF  TYPHOID   FEVER. 


107 


unknown  among  the  very  young,  as  the  diagram 
shows,  and  physicians  are  coming  to  believe  that  it 
is  more  prevalent  than  has  been  generally  supposed, 
many  cases  in  the  past  having  been  set  aside  merely 
as  infantile  diarrhea,  summer  complaint,  and  other  dis- 


COO       40 


Fig.  s. 
Diagram  Illustrating  the  Age  Distribution  of  Typhoid  Fever. 

eases  of  an  indefinite  character.  It  is  at  the  age  when 
young  men  and  women  come  to  maturity,  and  when 
they  are  likely  to  change  their  environment  in  many 
ways,  that  there  is  a  sudden  increase  in  the  typhoid 
death-rate.  Between  the  ages  of  20  and  25  it  reaches  its 
highest  point.  It  then  declines  gradually  until  about 
the  age  of  fifty,  after  which  it  remains  nearly  constant 


io8 


TYPHOID    FEVER. 


until  the  age  of  75,  when  it  drops  again  to  the  same  rate 
as  that  of  infancy. 

How  much  these  changes  are  due  to  relative  suscepti- 
bility at  different  ages,  how  much  to  acquired  immunity 
and  how  much  to  environment,  cannot  be  told.  All  of 
these  factors  are  probably  involved,  but  it  is  quite  as 
likely  that  the  maximum  number  of  typhoid  deaths  at 
the  age  of  about  25  years  results  from  certain  mathe- 
matical relations  of  the  curves  for  age  distribution  of 
population,  percentage  fatality,  and  rate  of  attack  than 
from  any  particular  susceptibility  at  that  age. 

A  study  of  age  distribution  in  certain  milk  epi- 
demics shows,  as  one  would  expect,  that  children  are 


, 

Per  Cent  of  Typhoid  Cases  at  Specified  Age. 

Age  in  Years. 

Water  ville. 

(Epidemic  Caused 

by  Water,) 

Stamford. 

(Outbreak  Caused 

by  Milk.) 

•-^0  to  10 

17 
38 
26 
10 
4 
5 

35 
24 
23 
12 

5 

I 

10  to  20 

20  to  30   . 

30  to  40 

40  to  50 

50  to  70 

Total 

100 

100 

more  liable  to  be  affected  than  older  people.  The 
Stamford  outbreak  is  an  extreme  instance  of  this.  For 
comparison,  the  age  distribution  there  obtained  is  placed 
beside  the  age  distribution  obtained  during  the  epidemic 
at  Waterville,  Maine,  which  was  due  to  water. 

To  a  very  great  extent  a  person  who  has  had  typhoid 


DISTRIBUTION    OF  TYPHOID   FEVER. 


109 


fever  is  immune  from  subsequent  attacks,  consequently 
in  the  case  of  older  people  a  substantial  percentage  may 
be  considered  as  non-susceptible;  otherwise  the  death- 
rates  at  the  older  ages  would  be  higher  than  are  given 
in  the  table. 

Sex  Distribution.  Typhoid  fever  is  more  common 
among  males  than  among  females,  as  may  be  seen  from 
the  following  figures,  and  from  those  given  in  the  table 
of  age  distribution. 


Year. 


1899 
1890 
1900 
1890 
1900 
1900 

1900 

1900 
1900 
1900 
1900 
1900 


Community. 


England  and  \\'ales  .... 
U.  S.  Registration  Area  .    .    . 

Do 

U.  S.  Cities 

Do 

U.  S.   Cities  (colored   popula- 

lation) 

U.  S.  Cities: 

Under  15  years  of  age     .    . 

Age  15  to  24 

Age  25  to  34 

Age  35  to  44 

Age  45  and  over 

U.  S.  Registration  Area  (Rural 

Districts) : 

Under  15  years  of  age     .    . 

15  to  24 

25  to  34 

35  to  44 

45  and  over  


Typhoid  Fever 

Death-rate 

per  100,000. 

Males. 

Females. 

23.2 

16.8 

52-4 

27.4 

57-4 

38- 1 

40.8 

28.8 

58.1 

41-5 

80.1 

58.0 

21.0 

23.0 

67.4 

46.3 

60.6 

32-4 

42.2 

27.4 

351 

24-3 

12.9 

15-9 

47.2 

37-5 

40.3 

26.8 

30.8 

21.3 

21.8 

19.7 

Percentage 

Excess  of 

Death-rate 

Among  Males. 


Per  Cent. 

38 
37 
36 

41 

40 

40 


45 
87 
54 
44 


-23 
26 


44 
10 


The  death-rate  is  about  35  to  40  per  cent  higher  among 
males  than  females,  but  this  percentage  varies  at  different 


no  TYPHOID    FEVER. 

ages.  Girls  acquire  the  disease  at  an  earlier  age  than 
boys,  so  that  in  the  case  of  children  less  than  15  years  old 
the  death-rate  is  greater,  but  only  slightly  greater,  among 
females  than  among  males.  As  age  increases,  this  changes 
until  at  the  age  of  25  or  30  years  the  death-rate  may  be  50 
to  80  per  cent  higher  among  males  than  among  females. 
It  seems  reasonable  to  suppose  that  these  differences  are 
due  to  differences  in  exposure.  In  childhood  the  dif- 
ference between  the  environment  of  the  two  sexes  is  not 
material;  but  in  middle  life,  when  the  activities  of  life 
are  greatest,  it  may  be  supposed  to  be  at  its  maximum; 
while  in  old  age  the  environments  again  tend  to  become 
similar.  Again,  it  is  likely  to  be  the  case  that  in  rural 
districts  the  environment  of  men  and  women  in  middle 
life  is  more  nearly  the  same  than  in  the  case  of  cities; 
and  the  preceding  table  shows  that  it  is  in  the  cities  that 
the  greatest  differences  between  the  occurrence  of 
typhoid  fever  in  the  two  sexes  are  most  marked. 

Racial  Distribution.  The  data  for  determining  the 
distribution  of  typhoid  fever  among  the  different  races 
are  altogether  too  imperfect  to  enable  any  general  con- 
clusion to  be  drawn.  The  records  of  the  last  United 
States  census  show  that  the  death-rate  among  the 
Scandinavian-bom  population  is  high,  and  among  the 
Russian-bom  low,  but  such  figures  as  these  probably 
show  the  effects  of  environment  more  than  the  suscepti- 
bility of  the  races.  Racial  differences  in  diet  may  have 
some  influence  in  the  occurrence  of  the  disease.  There 
is  some  reason  for  thinking  that  a  vegetable  diet  is  less 
conducive  to  abnormal  intestinal  conditions  than  a  meat 
diet,  and  it  has  been  often  remarked  that  the  amount  of 


DISTRIBUTIOX   OF  TYPHOID    FEVER.  Ill 

typhoid  fever  among  Italian  laborers  living  in  close 
quarters  under  poor  sanitary  conditions  is  much  less 
than  would  naturally  be  expected.  The  diet  of  Ameri- 
cans, as  a  nation,  contains  a  larger  percentage  of  meat 
than  that  of  European  nations.  This  idea,  however, 
has  little  or  no  statistical  basis,  and  must  not  be  too 
seriously  considered. 

As  to  the  colored  race  in  this  country,  environment 
seems  to  count  for  more  than  racial  susceptibility. 

In  the  cities  of  the  United  States  in  1900  the  typhoid 
death-rate  among  the  male  white  population  was  34.8 
per  100,000,  and  among  the  colored  population,  68.8,  - 
or  about  twice  as  much.  The  corresponding  figures  for 
females  were  29.8  for  the  white  population,  and  70.0 
for  the  colored.  This  difference  is  general  throughout 
the  southern  states,  where  the  colored  population  lives 
under  much  more  unfavorable  sanitary  conditions  than 
the  whites.  It  is  not  so,  however,  among  the  colored 
people  of  the  northern  states,  where  the  sanitar}'  con- 
ditions of  the  two  races  are  more  nearly  equal,  —  as,  for 
instance,  in  the  rural  districts  of  the  registration  area, 
where  in  1900  the  typhoid  death-rate  among  the  white 
population  was  25.5,  and  among  the  colored  population 
26.5  per  100,000. 

It  is  interesting  to  note  in  this  connection  that  between 
1890  and  1900  the  typhoid  fever  death-rate  among  the 
white  population  of  American  cities  decreased  from 
49.8  to  34.8  per  100,000,  or  30  per  cent,  while  the  death- 
rate  of  the  colored  population  decreased  from  70.0  to 
68.8,  or  less  than  2  per  cent.  In  the  registration  area, — 
New  York  and  parts  of  New  England, —  the  reduction 


112  TYPHOID    FEVER. 

in  the  death-rate  among  the  colored  population  was 
fully  as  great,  both  in  the  cities  and  in  the  rural  districts, 
as  among  the  white  population.  In  the  cities  outside 
the  registration  area  the  death-rate  among  the  colored 
population  increased  during  the  decade  from  67.2  to 
72.7  per  100,000,  although  the  death-rate  among  the 
white  population  decreased  from  61.5  to  44.6  per 
100,000. 

These  facts  all  tend  to  show  that  environment  rather 
than  susceptibility  is  the  controlling  factor  in  the  dis- 
tribution of  typhoid  fever  among  the  races. 

Occupation  Distribution.  From  the  nature  of  the  case, 
there  are  no  general  tendencies  showing  that  typhoid 
fever  is  more  closely  associated  with  one  occupation 
than  another,  except  in  so  far  as  occupation  is  related 
to"  sex,  age,  local  conditions,  etc.  Yet  a  study  of  the 
distribution  of  typhoid  cases  by  occupation  in  the  case 
of  any  particular  locality,  or  at  the  time  of  an  epidemic, 
often  gives  a  clew  to  the  source  of  the  disease.  In 
Washington,  D.C.,  during  the  summer  of  1906  (June  11- 
Nov.  i),  the  morbidity  rate  among  school  children  was 
500  per  100,000,  and  this  included  27  per  cent  of  all  the 
cases;  while  among  very  young  children  the  morbidity 
rate  was  185;  among  housewives,  223;  servants,  212; 
laborers,  259;  clerks,  193,  etc.  A  high  morbidity  rate 
among  children  suggests  the  probability  of  milk  infec- 
tion. 

Rural  and  Urban  Distribution.  Contrary  to  what 
many  people  suppose,  typhoid  fever  is  more  largely  a 
rural  disease  than  an  urban  disease,  meaning  by  rural 
small  communities  in  distinction  from  large  commun- 


DISTRIBUTION  OF  TYPHOID   FEVER. 


113 


ities.  In  cities,  great  epidemics  occur  at  intervals; 
but  in  the  small  settlements  of  the  country,  the  disease  is 
present  year  after  year,  with  here  a  victim  and  there  a 
victim,  and  this  inconspicuous  but  constant  succession 
of  cases  counts  far  more  than  the  spectacular  epidemics 
which  startle  the  readers  of  our  daily  papers.  Dr.  John 
S.  Fulton,  in  1903,  presented  to  the  American  Medical 
Association  some  striking  figures  illustrating  this  rela- 
tion between  urban  and  rural  typhoid,  which  may  be 
summarized  as  follows: 


Five  states  in  which  the  urban  population  was 
more  than  60%  of  the  total      

Six  states  in  which  the  urban  population  was  be- 
tween 40%  and  60% 

Seven  states  in  which  the  urban  population  was 
between  30%  and  40% 

Eight  states  in  which  the  urban  population  was 
between  20%  and  30% 

Twelve  states  in  which  the  urban  population  was 
between  10%  and  20% 

Twelve  states  in  which  the  urban  population  was 
between  o  and  10% 


Average 

Per  Cent 

of  Rural 

Population, 


30 
49 
67 

75 
87 
95 


Average 
Tjrphoid 

Fever 
Death-rate 
per 
100,000. 


42 
38 
46 
62 
67 


Comparisons  made  between  the  city  and  country  dis- 
tricts of  the  different  states  show  the  same  relation, 
although  in  some  years  exceptions  to  the  rule  may  be 
found.  The  figures  given  under  climatic  distribution 
sufficiently  illustrate  this  point. 

The  subject  of  rural  typhoid  fever  needs  far  more 


114 


TYPHOID    FEVER. 


attention  than  has  ever  been  given  to  it,  especially  in  the 
southern  states.  The  smaller  communities  have  not 
done  their  duty  in  stamping  out  the  disease.  It  has  been 
said  that  it  is  easier  to  save  dollars  than  to  save  dimes; 
in  the  same  way  it  is  easier  to  reduce  the  typhoid  fever 
death-rate  of  a  great  city  by  building  filters  and  sewerage 
works  than  to  give  attention  to  the  thousand  foci  of 
infection  scattered  through  the  villages  of  New  England, 
the  plantations  of  the  South,  and  the  lumber  camps  of  the 
Northwest. 

Climatic  Distribution.  Typhoid  fever  is  more  abun- 
dant in  warm  climates  than  in  cold  climates;  but  to  what 
extent  this  is  due  to  the  effect  of  temperature,  and  what 
to  the  nature  of  the  environment,  it  is  difficult  to  say. 
There  is  reason  to  believe  that  the  latter  is  the  more 
important  factor. 

In  the  United  States  typhoid  fever  increases  consider- 
ably from  north  to  south.  If  the  Atlantic  coast  and 
Gulf  coast  regions  are  followed  from  Maine  to  Texas, 
this  increase  is  very  evident,  as  the  following  census 
figures  show: 


Region. 

Per  Cent  which  the  Typhoid 
Deaths  in  1900  were 
of  the  Total 
Deaths. 

Rural. 

Cities. 

North  Atlantic  Coast  Region 

Middle  Atlantic  Coast  Region 

South  Atlantic  Coast  Region 

Gulf  Coast  Region 

1. 17 

2-54 
4-95 
6.16 

1.29 

115 
2.31 
2.38 

DISTRIBUTION   OF  TYPHOID   FEVER. 


115 


It  will  be  noticed  that  the  increase  in  the  rural  districts 
is  considerably  greater  than  in  the  cities,  —  presumably 
because  the  general  sanitary  conditions,  the  quality  of 
the  drinking-water,  etc.,  are  better  in  the  cities  than  in  the 
country,  especially  in  the  South. 

If  a  line  be  taken  down  the  hilly  and  mountainous 
regions  in  the  general  direction  of  the  Appalachian 
Mountains,  or  down  through  the  middle  West,  the  same 
distribution  will  be  seen. 


Region. 

Per  Cent  which  the  Typhoid 

Deaths  in  1900  were 

of  the  TotaJ 

Deaths. 

Rural. 

Cities. 

Northern  Hills  and  Plateaus 

Central  Appalachian 

1. 81 
2-57 
6-45 
7.61 

215 
3-59 
7.06 

I. 81 
1.92 
4. 16 

3.10 
3-35 
3-87 

Southern  Appalachian 

Southern  Interior  Plateaus 

Heavily  Timbered    Region    of    the  North- 
west       ■ 

Prairie  Region 

Southwest  Central 

There  are  some  exceptions  to  this  regular  increase  of 
typhoid  fever  southward.  For  example,  in  1900  the 
death-rate  was  higher  in  certain  parts  of  the  state  of 
Washington  than  in  Florida.  The  city  of  Winnipeg, 
Manitoba,  has  a  high  death-rate,  and  the  rates  in  many 
other  parts  of  Canada  are  high. 

Geographical  Distribution.  Typhoid  fever  is  much 
more  abundant  in  the  United  States  than  in  most  for- 


ii6 


TYPHOID    FEVER. 


eign  countries.  This  is  shown  by  the  following  data, 
taken  from  the  Mortality  Statistics  of  the  Bureau  of  the 
Census  for  1905. 


Date. 


1900 

1900 

1900-1904 


1902 
1900-1904 


1902 


Country. 


United  States 

United  States,  Registration  Area  . 
United  States,  Registration  Area  . 

Norway 

Switzerland 

Germany 

Holland 

Sweden 

Scotland 

England  and  Wales 

Ireland 

Belgium 

Hungary 

Italy 

Spain 


Typhoid  Death- 
rate  per 
100,000. 


47-3 
33-8 

33-7 
6.2 

6.5 
8.5 
8.6 
12.2 
12.  7 
12.9 
14.  2 
20.2 
28.3 
37-8 
45-8 


The  following  figures  show  the  typhoid  death-rates  in 
various  European  cities  about  the  year  1903:  — 


Berlin,  Germany  .  . 
Vienna,  Austria  .  .  . 
Hague,  Holland  .  .  . 
Berne,  Switzerland  .  . 
Copenhagen,  Denmark 
London,  England  .  . 
Brussels,  Belgium  .  . 
Paris,  France  .... 
Lisbon,  Portugal  .  . 
Madrid,  Spain  .  .  . 
St.  Petersburg,  Russia 


Typhoid  Death- 

rate  per 

100,000. 

5-0 

5 

I 

5 

I 

7 

0 

13 

3 

14 

4 

17 

2 

21 

7 

29 

4 

50 

0 

80 

7 

DISTRIBUTION   OF  TYPHOID   FEVER.  I17 

The  question  naturally  arises,  "Why  is  the  typhoid 
death-rate  so  much  lower  in  Western  Europe  than  in  the 
United  States?"  There  are  many  reasons  for  it.  Surface 
waters  used  without  filtration  are  less  frequent  abroad. 
In  Germany,  for  instance,  the  filtration  of  surface  waters 
is  required  by  law,  and  rigid  restrictions  are  in  force 
as  to  the  efficiency  necessary  to  be  obtained  by  the  filters. 
Probably,  too,  less  water  is  used  there  as  a  beverage. 
In  Europe,  milk  is  more  often  boiled  before  using,  and 
oysters  are  not  as  much  eaten  as  with  us.  Better  water 
and  safer  milk  having  materially  reduced  the  disease, 
the  secondary  causes,  such  as  contagion  and  carriage 
by  flies,  decrease  as  a  matter  of  course.  It  is  possible 
that  differences  in '  the  classification  of  disease  and 
incompleteness  of  records  may  influence  the  figures 
given  above,  but  they  do  not  materially  affect  the  com- 
parison. 

A  generation  ago  the  waters  of  Northern  Europe  were 
far  less  safe  than  they  are  to-day,  and  there  was  then 
good  reason  for  travelers  refraining  from  drinking  the 
public  supplies,  just  as  there  is  to-day  in  Southern  Europe 
and  in  the  Orient.  The  movement  for  obtaining  pure 
water-supplies  is,  however,  world-wide,  and  at  the  pres- 
ent time  the  average  water-supphes  in  England  and  in 
Northern  Europe  are  quite  as  safe  to  drink  as  the  average 
supplies  of  America. 

In  Japan  the  water-supplies  of  most  of  the  large 
cities  have  been  subjected  to  filtration  for  a  number  of 
years. 

It  is  said  that  typhoid  fever  is  an  infrequent  disease 
in  the  Philippine  Islands,  and  that  it   was    practically 


ii8 


TYPHOID    FEVER. 


unknown  before  the  time  of  the  American  occupation, 
thus  illustrating  Professor  Sedgwick's  statement  that 
typhoid  fever  is  a  disease  of  civilization.  Since  then,  to 
quote  from  a  report  to  the  Philippine  Commission,  "the 
disease  has  made  its  appearance  from  time  to  time  in 
various  parts  of  the  islands,  especially  at  places  at 
which  troops  were  stationed. "  At  Baguio  it  was  said 
that  the  near  approach  of  the  new  road,  with  its  swarms 
of  workmen  and  its  attendant  swarms  of  flies,  led  to  the 
temporary  introduction  of  several  diseases  which  had 
not  been  previously  present.  There  was  a  slight 
epidemic  of  typhoid  fever,  which  was  spread  by  flies, 
but  which  was  promptly  controlled  with  a  total  of 
only  seven  cases. 

In  the  city  of  Manila  itself  typhoid  fever  has  been 
by  ho  means  absent,  as  the  following  figures  show. 
During  the  year  ending  Sept.  i,  1905,  there  were  122 
deaths,  and  during  the  following  year,  45.  During  the 
year  ending  June  30,  1905,  there  were  23  cases  and  5 
deaths  among  the  United  States  troops. 

MANILA,  PHILIPPINE  ISLANDS,   SEPT.  i,    1904,  TO  SEPT.  i, 

1905. 


Race. 

Popula- 
tion 

Deaths 
from  All 

Death-rate 

per  1000. 

All 

Causes. 

Typhoid 
Fever 

Typhoid 
Death-rate 

(1903). 

Causes. 

Deaths. 

per 
100,000. 

Americans  .    .    . 

4,389 

39 

8.88 

I 

25.6 

Philippines      .    . 

189,782 

8,453 

44 

54 

no 

58.2 

Spaniards    .    .    . 

2,528 

51 

20 

17 

}    ^ 

J  160.5 

Other  Europeans 

1,117 

14 

12 

53 

Chinese    .... 

21,230 

343 

16 

15 

5 

23.6 

All  others    .    .    . 

26 

29 

05 

Total    .    .    . 

219,941 

8,926 

40 

58 

122 

55-7 

DISTRIBUTION   OF  TYPHOID  FEVER.  119 

Apparently  these  figures  overstate  the  amount  of 
typhoid  present,  for  recent  studies  carried  on  in  the 
government  laboratory  have  shown  that  a  large  pro- 
portion of  the  so-called  typhoid  fever  cases  fail  to  respond 
to  the  Widal  test. 

In  one  of  the  surgeon's  reports  to  the  Commission  it 
is  stated  that  "with  the  rapid  increase  in  the  use  of 
milk  in  the  city  of  Manila  and  because  of  the  thickly 
populated  watershed  from  which  the  city  obtains  its 
water-supply,  it  is  rather  probable  that  Manila  is  in 
considerable  danger  of  becoming  thoroughly  infected 
with  typhoid  fever  unless  the  greatest  precautions  are 
taken  to  prevent  its  gaining  a  foothold. " 

During  1 898-1 902  the  average  death-rate  for  typhoid 
fever  in  various  cities  of  the  West  Indies  and  South 
America  were  as  follows :  — 


Rate  per 
100,000. 


Havana,  Cuba  .  .  . 
San  Jose,  Costa  Rica 
Santiago  de  Chile    .    . 

Rio  Janeiro 

Buenos  Aires    .    .    .    . 


39-3 
74-9 
48.3 
15-9 
22.0 


Geological  Distribution.  Studies  of  the  distribution  of 
typhoid  fever  along  east  and  west  lines  of  the  United 
States  do  not  reveal  any  changes  that  can  be  attributed 
to  altitude,  to  rainfall,  or  to  any  geographical  or  climatic 
influence.  There  does  seem  to  be,  however,  some  coinci- 
dence of  high  typhoid  fever  rates  and  the  presence  of  a 
clayey  soil.     Within  the  area  of  the  glacial  drift,  and 


120  TYPHOID    FEVER. 

along  the  eastern  sea-coast,  the  disease  is  somewhat  less 
abundant  than  in  the  alluvial  regions  of  the  southern 
and  central  states.  This  area  is  so  largely  coincident 
with  the  presence  of  the  negro  race,  however,  that  no 
sweeping  generalization  can  be  made;  yet  it  is  evident 
that  with  an  impervious  soil,  the  opportunities  for  surface 
contamination  of  streams,  springs,  and  wells  are  greater 
than  in  a  sandy  region  where  the  natural  purification 
of  the  soil  plays  a  larger  part.  The  soil  factor  must  not 
be  given  too  much  weight,  however;  for  it  is  to  be 
remembered  that  in  England,  where  the  soil  is  heavy,  the 
typhoid  rate  is  comparatively  low. 

The  opportunities  for  the  pollution  of  wells  are  some- 
what increased  in  a  limestone  region,  where  cracks  and 
crevices  in  the  rocks  may  exist,  but  this  factor  does  not 
manifest  itself  in  looking  at  the  distribution  of  the  disease 
over  large  areas. 

Hydrographic  Distribution.  Typhoid  fever  is  often 
abundant  along  the  courses  of  streams,  especially  where 
the  streams  are  used  both  for  the  disposal  of  sewage 
and  for  the  supply  of  drinking-water  to  the  cities  along 
the  shores.  Examples  of  this  condition  along  the 
Penobscot  River,  the  Merrimac,  the  Hudson,  and  other 
streams  are  referred  to  elsewhere. 

It  is  said  that  all  through  the  Potomac  and  Shenan- 
doah valleys  typhoid  fever  has  been  constantly  prevalent 
ever  since  the  Civil  War,  and  no  doubt  much  of  the 
typhoid  fever  in  the  South  to-day  represents  a  legacy 
left  by  the  armies  engaged  in  that  conflict. 

The  disease  is  sometimes  abundant  at  sea  beaches  and 
along  the  shores  of  bodies  of  water  into  which  sewage  is 


DISTRIBUTION   OF  TYPHOID    FEVER. 


121 


discharged.  Epidemics  of  some  magnitude  have  resulted 
from  bathing  in  infected  waters;  and  it  has  been  sug- 
gested that  along  water-fronts  where  sewage  is  discharged 
under  the  wharves,  flies  may  act  as  carriers  of  the  bacilli 


Fig.  7. 

Diagram  Showing  the  Seasonal  Distribution  of  Typhoid  Fever  in  the 

United  States.     (From  the  U.  S.  Census  Bureau  of  1900.) 

from  the  deposits  left  by  the  tides  to  persons  dwelling  or 
working  near  the  shores.  Mr.  D.  D.  Jackson  in  a 
report  to  the  Merchants'  Association  has  recently  empha- 
sized the  importance  of  this  factor  in  New  York  City. 


122 


TYPHOID    FEVER. 


Fig.  8. 


Diagram  Showing  the  Seasonal   Distribution  of  Typhoid  Fever  in 
Certain  Cities  of  the  United  States. 


DISTRIBUTION   OF  TYPHOID   FEVER. 


123 


Seasonal  Distribution.  In  the  United  States  the 
normal  seasonal  distribution  of  typhoid  fever  is  shown 
by  Fig.  7.  June  is  the  month  when  the  disease  is 
usually  least  abundant.  During  the  summer,  it  increases 
gradually  until  it  attains  a  maximum  in  October,  then 


180 
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Diagram  Showing  the  Seasonal  Distribution  of  Typhoid  Fever  in  Albany, 

N.  Y.,  before  and  after  the  Fihration  of  the  Public  Water-Supply. 

it  gradually  decreases,  though  with  some  slight  fluctua- 
tions during  the  winter  and  spring  months. 

This  normal  curve  holds  approximately  for  most 
rural  sections  and  for  cities  which  are  provided  with 
good,  or  fairly  good,  water-supplies.  Thus  the  sea- 
sonal distribution  of  typhoid  fever  in  New  York  City 
follows  the  normal  curve.  In  cities  which  have  polluted 
water-supplies  there  is  likely  to  be  a  more  irregular 
occurrence  of  the  disease,  with  maxima,  or  sub-maxima, 


124 


TYPHOID    FEVER. 


in  the  colder  part  of   the  year.     The  occurrence  of   an 
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Fig.  10. 

Diagram  Showing  the  Relation  between  Atmospheric  Temperature 
and  Seasonal  Distribution  of  Typhoid  Fever.  (After  Sedgwick 
and  Winslow.) 


DISTRIBUTION   OF  TYPHOID  FEVER.  125 

curve.  The  diagram  on  page  122  shows  the  seasonal 
distribution  of  the  disease  in  cities  where  the  pubHc 
water-supply  is  of  fairly  good  sanitary  quality,  and  in 
cities  where  it  is  polluted. 

It  will  be  seen  from  these  curves  that  the  character  of 
the  water-suppHes  is  best  indicated  by  the  typhoid  fever 
records  during  the  winter  and  spring  months.  Of  the 
three  largest  cities,  New  York  has  the  best  water,  Chicago 
next,  and  Philadelphia  next;  and  this  is  the  order  of 
the  typhoid  curves  during  the  first  half  of  the  year. 
Not  so,  during  the  summer  and  autumn.  Here  the 
differences  between  the  three  are  much  less,  and  the 
rate  at  Chicago  is  highest.  There  •  is  reason  to  believe 
that  during  this  season  of  the  year  the  effect  of  the 
quality  of  the  milk-supply,  and  the  influences  of  flies 
and  general  sanitation,  exert  a  preponderating  influence 
on  the  height  of  the  curve. 

Even  more  striking,  perhaps,  is  the  change  in  the 
seasonal  distribution  of  typhoid  fever  after  a  city  has 
changed  its  source  of  water-supply  from  bad  to  good, 
or  has  improved  the  character  of  its  supply  by  filtration. 
Albany  is  a  good  illustration  of  this. 

Many  theories  have  been  advanced  to  account  for 
the  greater  general  prevalence  of  typhoid  fever  in  the 
autumn  than  at  other  seasons  of  the  year.  That  it 
is  in  some  way  related  to  temperature  can  scarcely  be 
questioned.  Sedgwick  and  Winslow  have  illustrated 
this  by  a  beautiful  series  of  diagrams  for  various  cities 
in  different  parts  of  the  world.  Some  of  these  are 
reproduced  in  Fig.  10. 

The   way   in   which   the   typhoid   curves   follow   the 


126  TYPHOID    FEVER. 

temperature  curves  is  very  striking.  In  order  to  better 
show  the  correspondence,  the  typhoid  fever  curves 
have  been  set  back  two  months,  —  thus  allowing  for 
the  period  elapsing  between  the  date  of  infection  and 
the  date  of  death.  Sedgwick  and  Winslow  explain 
this  correspondence  between  temperature  and  typhoid 
by  the  general  unfavorable  influence  which  cold  exerts 
on  the  persistence  of  the  typhoid  bacillus  outside  the 
body.  It  is  held  that  during  warm  weather  trans- 
mission by  contact  is  more  frequent,  and  infection  by 
other  methods  rendered  more  likely  by  reason  of  an 
increased  longevity  of  the  bacilli. 

Other  reasons  for  the  greater  prevalence  of  typhoid 
fever  in  warm  weather  will  naturally  suggest  themselves. 
Flies  and  other  insects  are  more  abundant  and  more 
active  in  summer;  bacteria  multiply  faster  in  milk;  fruits, 
berries,  and  uncooked  foods  are  more  commonly  used; 
more  water  is  drunk,  and  ice  is  put  into  it;  wells  are 
lower,  and  the  danger  of  contamination  is  thereby  in- 
creased; traveling  is  more  common,  and  opportuni- 
ties for  transmission  by  contagion  are  thus  greater. 
The  consumption  of  oysters,  on  the  other  hand,  is 
less  in  summer  than  in  winter.  The  idea  has  been 
recently  suggested  by  a  number  of  sanitarians,  that 
the  greater  prevalence  of  diarrheal  diseases  of  a  mild 
type  and  of  various  intestinal  disorders  during  the 
hot  weather,  due  to  bad  milk,  unripe  fruit,  etc., 
may  act  as  exciting  causes,  and,  by  reducing  a  per- 
son's vitality  and  by  irritating  the  intestinal  walls, 
may  increase  the  chance  of  infection  among  those 
who  are   exposed.     The   somewhat   greater  proportion 


DISTRIBUTION   OF  TYPHOID   FEVER.  127 

of  typhoid  cases  among  young  people  during  the  sum 
mer  than  during  the  winter  lends  countenance  to  this 
theory,  as  well  as  the  fact  that  typhoid  epidemics  are 
quite  frequently  preceded  or  accompanied  by  an  unusual 
amount  of  diarrhea.  On  the  other  hand,  the  testimony  of 
the  commission  that  studied  the  occurrence  of  typhoid  fever 
in  our  army  during  the  Spanish  War  is  to  the  contrary. 

Vacation  Typhoid.  The  autumnal  increase  of  typhoid 
fever  in  cities  is  sometimes  referred  to  as  "vacation 
typhoid,"  —  the  idea  being  that  it  is  due  to  patients 
returning  sick  from  the  country.  This  theory  is  based 
on  the  fact  that  typhoid  fever  is  at  present  chiefly  a 
rural  disease,  and  so  far  as  this  goes  it  is  correct.  But 
the  notion  of  "vacation  typhoid"  has  been  very  much 
overworked,  and,  as  a  matter  of  fact,  it  does  not  to  any 
very  material  extent  account  for  the  summer  and 
autumnal  increase  of  typhoid  fever  in  the  large  cities.  In 
Washington  it  was  estimated  that  during  the  summer 
and  autumn  of  1906,  85  per  cent  of  the  cases  were 
contracted  within  the  city,  and  studies  of  imported 
cases  in  other  cities  have  given  similar  figures. 

Cities  which  have  polluted  water-supplies  generally 
show  this  fact  by  an  unusual  prevalence  of  typhoid 
fever  at  other  seasons  than  the  summer  and  autumn, 
and  most  of  the  severe  epidemics  due  to  infected  water 
have  occurred  during  the  late  autumn,  winter,  or  spring; 
but  in  the  cases  of  cities  supplied  with  water  from 
impounding  reservoirs  located  on  watersheds  more  or 
less  polluted,  opportunities  for  the  transmission  of 
infection  may  be  increased  during  the  late  summer. 
The  reservoirs  are  then  likely  to  be  drawn  down,  so  that 


128 


TYPHOID    FEVER. 


a  hard  rain  may  carry  infection  rapidly  through  them  to 
the  city.  It  seems  to  be  a  fact  that  in  such  cities  the 
amount  of  typhoid  fever  is  greater  during  years  of  dry 
summers. 

Chronological  Distribution.  Typhoid  fever  is  grad- 
ually becoming  less  frequent  as  a  cause  of  death.  This 
is  due  partly  to  a  reduction  in  fatality  through  better 
medical  treatment,  but  is  chiefly  due  to  a  reduction  of 
infection  by  reason  of  better  water-supplies  and  a  more 
logical  sanitary  regime  based  on  the  germ  theory  of 
disease.  The  chronological  distribution  of  the  disease 
will  be  repeatedly  referred  to  in  other  places,  but  at  this 
point  it  may  be  sufficiently  illustrated  by  the  following 
average  figures  for  twelve  states,  including  all  the  New 
England  states  and  New  York  and  New  Jersey,  Mary- 
land, California,  Minnesota,  and  Michigan. 


Year. 

Average  Typhoid  Fever 
Death-rate  per  100,000. 

Year. 

Average  Typhoid  Fever 
Death-rate  per  100,000. 

1880 
1885 
1890 

55 
46 
36 

189s 
1900 

1905 

28 

23 

21 

A  generation  ago,  about  one  person  in  every  five  or 
six  in  the  United  States  was  bound  to  have  the  typhoid 
fever  at  some  time  in  his  life,  and  one  person  in  every 
fifteen  or  twenty  died  in  an  uphill  fight  against  this 
insidious  enemy.  To-day,  under  the  average  conditions 
in  the  United  States,  the  chance  of  having  the  typhoid 
fever  at  some  time  between  the  cradle  and  the  grave  is 
only  about  one  in  ten.     What  is  the  future  to  be  ?     The 


DISTRIBUTION    OF  TYPHOID   FEVER. 


129 


prospect  is  bright.  The  indications  are  that  the  disease 
is  soon  to  become  much  less  prevalent  than  it  is  to-day. 
In  another  generation  the  death-rate  ought  not  to  be 
over  a  third  or  a  quarter  of  what  it  nov^  is,  —  and  who 
can  say  that  the  disease  will  not  be  all  but  obliterated, 
just  as  smallpox  has  almost  vanished  from  our  midst  ? 

Typhoid  fever  has  been  decreasing  in  foreign  countries. 
The  following  figures  show  this  decrease  for  England 
and  Wales: 


Year. 

Typhoid  Death-rate 

Year 

Typhoid    Death-rate 

per  100,000. 

per  100,000. 

1870 

1875 
1880 

38 

37 
26 

1890 

1895 
1900 

17 
17 
17 

1885 

17 

1905 

9 

Effect  of  Spanish  War.  The  Spanish  War  caused 
something  of  a  set-back  to  the  gradual  decrease  of  typhoid 
fever  in  America.    The  enormous  number  of  cases  that 


TABLE   SHOWING   THE   TYPHOID   FEVER   DEATH-RATE 
FOR   NINE   STATES. 


Year. 

Death-rate  per  100,000. 

Year. 

Death-rate  per  100,000. 

1895 
1896 

1898 

30-5 
27.7 

21-5 

25.2 

1899 
1900 
1901 
1902 

235 
27.9 

25.2 
20.  2 

occurred  in  the  military  camps  caused  the  disease  to  be 
quite  generally  scattered  through  the  country,  and  these 


I30 


TYPHOID    FEVER. 


new  foci  gave  rise  to  various  outbreaks,  with  the  resuk 
that  the  general  death-rate  temporarily  increased.  Men- 
tion is  made  elsewhere  of  the  fact  that  in  New  York  City 
and  in  Brooklyn  the  typhoid  fever  rate  in  1898  increased 


Fig.  II. 


on  account  of  the  soldiers  returning  from  the  war.  A  simi- 
lar increase  occurred  in  many  other  cities ;  for  instance,  in 
Portland,  Maine,  the  death-rate  rose  from  24  to  76  per 
100,000.  Statistics  collected  for  nine  states  showed  a 
decided  increase  during  the  same  year.  For  instance,  the 


DISTRIBUTION   OF  TYPHOID   FEVER.  13 1 

average  death-rate  had  been  21.5  in  1897,  but  rose  to 
25.2  in  1898,  falling  again  to  23.5  in  1899. 

The  amount  of  typhoid  fever  in  1899  was  unexpectedly 
low,  but  in  1900  it  again  rose,  and  was  even  higher  than 
in  1898.  Whether  or  not  this  increase  was  due  to  the 
spread  of  infectious  matter  by  the  soldiers,  cannot  be  said. 
It  may  have  been;  but  if  this  were  so  the  question  comes. 
Why  was  not  the  rate  high  in  1899  ?  Since  1900  there  has 
been  a  general  reduction  in  the  prevalence  of  typhoid 
fever,  but  1904  was  another  bad  year.  During  this  year 
the  great  epidemics  occurred  in  Ithaca,  Butler,  and  else- 
where. There  are  no  data  for  explaining  these  waves  of 
typhoid  which  sometimes  sweep  over  the  country. 

Distribution  by  Causes.  To  state,  with  any  degree  of 
exactness,  the  proportion  of  cases  of  typhoid  fever  due  to 
different  causes,  is  absolutely  impossible  from  such  data 
as  now  exist,  and  yet  this  is  a  question  often  asked. 
Even  if  the  data  were  at  hand,  it  could  be  answered 
only  in  a  very  general  way,  for  the  relative  effects  of 
different  causes  are  not  the  same  at  all  times  and  in  all 
places.  From  a  study  of  the  statistics,  however,  a  rough 
approximation  can  be  made  of  the  more  important 
causes,  though  the  results  are  hardly  more  valuable  than 
a  shrewd  guess. 

When  a  contaminated  public  water-supply  is  suddenly 
improved  in  quality  by  the  installation  of  a  filter  plant, 
there  is  nearly  always  a  decided  fall  in  the  typhoid  fever 
death-rate.  Cities  which  have  pure  water  have  a  gen- 
erally lower  death-rate  than  those  which  have  an  impure 
supply.  These  differences  may  serve  as  a  rough  measure 
of  the  amount  of  typhoid  fever  due  to  impure  public 


132  TYPHOID    FEVER. 

water-supplies.  The  average  typhoid  death-rate  in 
American  cities  is  about  35  per  100,000.  The  cities  in  the 
north  which  have  safe  water-suppHes  have  lower  rates,  — 
usually  as  low  as  20,  and  frequently  as  low  as  15  or  even 
10.  Taking  the  country  over,  perhaps  20  may  be  taken 
as  an  average  figure.  The  difference  between  20  and  35 
may  be  considered,  therefore,  as  being  due  to  infected 
public  water-supplies.  Of  the  "residual  typhoid,"  the 
most  potent  causes  are  probably  infected  milk,  and  direct 
infection  by  contagion,  by  flies,  etc.  Oysters,  vegetables, 
and  other  foods  really  play  a  very  insignificant  part  in 
the  general  typhoid  death-rate. 

A  number  of  years  ago  infected  water  probably  caused 
more  typhoid  fever  than  all  the  other  causes  combined. 
That  is  not  the  case  to-day  when  the  country  as  a  whole  is 
considered,  although  it  is  still  the  most  important  cause, 
and  m  some  cities,  as  in  Pittsburgh  and  Philadelphia, 
it  still  overshadows  all  other  causes.  The  long-continued 
struggle  for  pure  water  is  bearing  fruit,  and  to-day  in 
many  American  cities,  and  even  in  entire  states,  where  the 
public  water-supplies  are  well  guarded  from  pollution, 
infection  by  water  has  come  to  be  a  secondary  cause  of 
the  disease. 

In  a  general  sort  of  way  it  may  be  said  that  in  the  cities 
of  the  United  States,  at  the  present  time,  about  40  per 
cent  of  the  typhoid  fever  is  due  to  water,  25  per  cent  to 
milk,  30  per  cent  to  ordinary  contagion  (including  fly 
transmission),  and  only  about  5  per  cent  to  all  other 
causes.  In  cities  supplied  with  pure  well  water  or  fil- 
tered water,  the  effect  of  water  is  negligible;  where  the 
water  is  impure,  it  is  still  the  most  important  cause  of  the 


DISTRIBUTIOX    OF   TYPHOID   FEVER.  1 33 

disease.  In  the  case  of  rural  districts  there  are  no  data 
to  show  the  relative  eflFect  of  infected  wells,  infected 
milk,  and  direct  infection,  but,  in  all  probability,  the 
"honors   are   about   even." 

^^^lile  the  care  of  water-supplies  cannot  be  in  any 
degree  relaxed,  efforts  for  further  reducing  the  disease 
must  be  directed  to  causes  other  than  water.  It  is  the 
realization  of  this  fact  that  explains  in  part  the  present 
strenuous  struggle  which  is  being  made  in  our  large 
cities  to  improve  the  milk-supply.  In  many  ways  the 
milk  problem  is  more  difficult  than  the  water  problem, 
as  the  sources  of  supply  are  so  numerous,  the  commodity 
is  such  a  delicate  one  to  handle,  and  its  distribution  so 
complicated.  When  one  considers  the  difl&culties  of  the 
milk  situation,  and  the  large  percentage  of  the  disease  due 
to  personal  contact,  that  is  to  contagion,  the  wisdom  of 
stamping  out  the  disease  at  the  bedside  must  be  evident 
to  every  one. 


CHAPTER  VIII. 
TYPHOID   FEVER   EPIDEMICS. 

From  time  to  time,  in  one  place  or  another,  typhoid 
fever  suddenly  increases  until  it  is  said  to  be  epidemic. 
If  the  increase  is  confined  to  a  small  portion  of  the  com- 
munity and  is  more  or  less  localized,  it  is  usually  termed 
a  "local  outbreak,"  or  a  "sporadic  outbreak;"  but  if  it 
is  widely  spread  and  can  be  attributed  to  some  general 
cause,  as  the  water-supply,  or  the  supply  of  some  large 
milk  dealer,  it  may  be  fairly  termed  an  epidemic.  There 
is  no  necessity,  however,  for  drawing  a  fine  distinction 
between  the  two,  as  the  difference  is  merely  one  of  mag- 
nitude; but  it  will  often  be  wise  to  use  the  term  "out- 
break "  rather  than  "  epidemic,"  in  order  to  prevent 
undue  excitement  and  avoid  the  opprobrium  attached  to 
the  larger  word. 

A  study  of  typhoid  fever  epidemics  forms  a  necessary 
part  of  the  history  of  our  subject,  and  from  them  many 
lessons  in  sanitary  science  may  be  learned.  It  will  be 
instructive  to  consider  in  some  detail  a  few  of  the  more 
important  epidemics  of  typhoid  fever  which  have  been 
traced  to  different  causes.  Those  chosen  for  illustration 
have  been  selected  either  by  reason  of  their  magnitude, 
or  because  they  illustrate  some  new  or  interesting  case  of 
infection.     The  data  given  are  taken  from  well-known 

•34 


TYPHOID  FEVER  EPIDEMICS.  1 35 

authorities,  and  references  to  more  detailed  accounts  are 
given  in  the  appendix. 

Classification  of  Epidemics.  The  epidemics  and  out- 
brealis  of  typhoid  fever  to  be  described  may  be  classified 
according  to  their  suspected  causes  as  follows : 

I.    Epidemics  due  to  infected  water: 

1.  Epidemics  caused  by  the  sudden  infection  of  a  water- 

supply  popularly  supposed  to  be  of  good  quality. 
PhTnouth,  Pa. 
Xew  Haven,  Conn. 
Ithaca,  X.  JA 
Scranton,  Pa.  \ 

2.  Epidemics  caused  by  water  constantly  subject  to  con- 

tamination. 

a.     River  water. 

Lowell  and  Lawrence,  Mass. 
Watenille  and  Augusta,  ^Maine. 
Pittsburgh  and  Allegheny,  Pa. 
v/'6.     Lake  water. 

Chicago,  ni. 
Cleveland,  Ohio. 
Burlington,   Vt. 

3.  Epidemics  caused  by  water  accidentally  infected. 

Butler,  Pa". 
Lowell,  Mass. 
Millinocket,  Maine. 
Baraboo,  Wis. 
Steamer  "Northwest." 

4.  Epidemics   and   outbreaks   caused   by   infected   ground 

water. 

Lausen,  S\^"itzerland. 
Basingstoke,  England. 
Newport,  R.I. 
Auxerre,  France. 
Trenton,  N.J. 
!Mount  Savage,  Md. 
//.     Epidemics  and  outbreaks  due  to  contagion,  flies,  and  general 
uncleanliness : 

New  Haven  County  Jail. 
Winnipeg,  Manitoba. 

United    States    ^Slilitar}-    Camps    during    the 
Spanish  War. 


136  TYPHOID    FEVER. 

III.  Outbreaks  due  to  injected  milk: 

Somerville,  Mass. 
Springfield,  Mass. 
Stamford,  Conn. 
Marlborougli,  Mass. 
Waterbury,  Conn. 
Montclair,  N.J. 

IV.  Outbreaks  due  to  infected  oysters  and  other  shell-fish: 

Wesleyan  University,  Middletown,  Conn. 
Winchester-Southampton,  England. 
Lawrence,  Long  Island. 

V.     Outbreaks  due  to  infected  fruit  and  vegetables: 
Springfield  (1905). 

VI.     Outbreaks  due  to  infected  ice: 
Ogdensburg,  N.Y. 

VII.     Outbreaks  due  to  other  causes,  such  as  cream,  ice-cream,  various 
foods: 

No  specific  examples  described. 

Epidemics  Due  to  Injected  Water.  ■ 

The  Pljmiouth  Epidemic.  Among  the  typhoid  fever 
epidemics  which  have  occurred  in  America  that  at 
Plymouth,  Pa.,  deserves  first  mention,  partly  for  the 
reason  that  it  was  one  of  the  first  large  epidemics  where 
the  cause  was  definitely  ascertained,  and  partly  because 
of  the  influence  which  the  lessons  taught  by  it  have  had 
on  sanitary  science  in  this  country. 

The  epidemic  occurred  in  the  spring  of  1885.  Plym- 
outh at  that  time  was  a  mining  town  of  about  8000 
inhabitants.  It  had  a  public  water-supply  derived  from 
a  stream  which  drained  an  almost  uninhabited  water- 
shed, and  the  water  was  stored  in  a  series  of  four 
small  reservoirs.  The  highest  of  these  reservoirs  had 
a  capacity  of  5,000,000  gallons;  the  next,  3,000,000; 
the  next,  1,700,000;  and  the  lowest,  nearest  the  city  and 


TYPHOID   FEVER  EPIDEMICS.  1 37 

used  as  a  distributing  reservoir,  300,000  gallons.  This 
water-supply,  though  apparently  satisfactory  in  quality, 
was  not  sufficient  at  all  times  for  the  needs  of  the  city, 
and  occasionally  it  was  necessary  to  supplement  it  by 
pumping  from  the  Susquehanna  River.  Well  waters 
were  also  used  by  some  of  the  inhabitants.  As  it  turned 
out,  neither  the  well  water  nor  the  polluted  Susque- 
hanna water  played  any  part  in  the  epidemic,  which, 
through  the  efforts  of  Dr.  L.  H.  Taylor  of  Wilkesbarre, 
and  others,  was  found  to  have  been  caused  by  the 
"pure  mountain  stream"  supply  of  the  Plymouth 
Water  Company. 

It  is  unnecessary  to  follow  here  all  the  steps  by  which 
the  epidemic  was  traced  to  its  origin;  it  will  be  simpler 
to  recite  the  pertinent  events  chronologically,  and  this 
will  also  indicate  more  clearly  the  relation  between 
cause  and  effect. 

In  an  open  clearing  near  the  banks  of  the  stream  and 
just  below  the  upper  reservoir,  there  existed  one  of  the 
few  houses  on  the  watershed.  The  man  who  occupied 
this  house  went  to  Philadelphia  on  Dec.  24,  1884,  and 
on  Jan.  2,  1885,  returned  home  ill  with  typhoid  fever. 
It  was  a  severe  case.  The  patient  was  in  bed  for  many 
weeks.  By  the  first  of  March  he  was  convalescent,  but 
a  relapse  occurred,  and  it  was  the  middle  of  April  before 
the  physician's  visits  were  discontinued.  "During  the 
course  of  his  illness,  his  night  dejecta  were  thrown 
without  disinfection  upon  the  snow  and  frozen  ground, 
toward  and  within  a  few  feet  of  the  edge  of  the  high  bank 
which  sloped  precipitously  down  to  the  stream  supplying 
the  town  with  water."     "The  dejecta  passed  during  the 


138  TYPHOID    FEVER. 

day  were  emptied  into  a  privy  a  little  farther  back,  the 
contents  of  which  laid  almost  upon  the  surface  of  the 
ground,  so  that  at  the  first  thaw  or  rain  they  too  would 
pass  down  the  sloping  bank  and  into  the  stream." 

Until  the  latter  part  of  March  the  ground  remained 
frozen  and  covered  with  snow,  and  under  these  con- 
ditions it  is  improbable  that  the  dejecta  reached  the 
water  of  the  stream.  But  during  the  last  week  in 
March  there  was  a  thaw,  the  air  temperature  increased 
rapidly  until,  on  April  4,  the  maximum  was  70  degrees. 
During  these  few  days  of  warm  weather  the  accumulated 
dejecta  of  many  weeks  probably  found  their  way  into 
the  stream  which  supplied  the  town  with  water. 

On  the  evening  of  March  26,  the  superintendent  of 
the  water  company  visited  the  reservoirs  and  found  that 
the  two  lower  ones  were  almost  empty,  while  the  one 
just  below  the  house  where  the  typhoid  patient  lived, 
was  filling  rapidly.  He  found,  however,  that  the  short 
pipe  which  allowed  the  water  to  discharge  from  the 
bottom  of  this  reservoir  into  the  stream  leading  to  the 
reservoir  below  it  was  frozen,  and  he  caused  a  fire  to 
be  built  to  melt  the  ice  in  the  pipe.  This  done,  the 
water  flowed  from  the  bottom  of  this  reservoir  down 
through  the  two  reservoirs  below  it,  and  thence  into  the 
town,  where  in  all  probability  it  first  arrived  some  time 
between  March  28  and  April  4  or  5,  —  that  is,  from 
two  days  to  a  week  after  it  was  let  down  from  the 
third  reservoir. 

The  first  case  of  typhoid  fever  in  the  town  occurred 
on  April  9,  and  from  this  time  on  the  disease  spread 
rapidly.     During    the  week  beginning  April    12,   from 


TYPHOID  FEVER  EPIDEMICS.  1 39 

50  to  100  new  cases  appeared  daily,  and  it  is  said  that 
on  one  day  200  new  cases  were  reported.  All  classes 
of  people  were  attacked  in  all  parts  of  the  town,  until, 
before  the  epidemic  ceased,  out  of  the  8000  inhabitants, 
1104  contracted  the  disease,  and  114  died. 

This  epidemic,  as  Dr.  Taylor  said  in  his  report, 
"was  one  of  the  most  remarkable  ones  in  the  history  of 
typhoid  fever,  and  taught  important  lessons,  though  at 
a  fearful  cost.  One  is,  that  in  any  case  of  typhoid  fever, 
no  matter  how  mild,  or  how  far  removed  from  the 
haunts  of  men,  the  greatest  possible  care  should  be 
exercised  in  thoroughly  disinfecting  the  poisonous  stools. 
The  origin  of  all  this  sorrow  and  desolation  occurred 
miles  away  on  the  mountain  side,  far  removed  from 
the  populous  town,  and  in  a  solitary  house  situated  upon 
the  banks  of  a  swift-running  stream.  The  attending 
physician  did  not  know  that  this  stream  supplied  the 
reservoirs  with  drinking-water.  Here,  if  at  any  place, 
it  might  seem  excusable  to  take  less  than  ordinary 
precautions;  but  the  sequel  shows  that  in  every  case  the 
most  rigid  attention  to  detail  in  destroying  these  poison- 
ous germs  should  be  enjoined  upon  nurses  and  others 
in  charge  of  typhoid  fever  patients,  while  the  history  of 
this  epidemic  will  but  add  another  to  the  list  of  such 
histories  which  should  serve  to  impress  medical  men, 
at  least,  with  the  great  necessity  for  perfect  cleanli- 
ness, —  a  lesson  which  mankind  at  large  is  slow  to 
learn." 

The  epidemic  is  interesting  to  bacteriologists  from 
the  fact  that  it  throws  some  light  upon  the  ability  of 
the  typhoid  bacillus  to  survive  the  apparently  unfavor- 


140 


TYPHOID    FEVER. 


able  conditions  of  winter.  Some  of  the  bacilli  at  least 
must  have  lived  and  retained  their  virulence  in  the 
frozen  fecal  matter  for  many  weeks. 

The  New  Haven  Epidemic.  In  the  early  spring  of 
1901  an  epidemic  of  typhoid  fever  occurred  in  New 
Haven,  Conn,,  which  was  similar  in  many  ways  to  that 
which  occurred  in  Plymouth  in  1885.  During  April, 
May,  and  June,  514  cases  occurred,  resulting  in  73 
deaths.  The  epidemic  began  about  the  middle  of  March, 
and  increased  as  shown  by  the  following  figures : 


Period. 

Number 
of  Cases. 

Period. 

Number 
of  Cases. 

March  20-26,  1901    .    . 
March  27-31,  1901    .    . 
April  1-5,  1901       .    .    . 
April  6-10,  1901     .    .    . 

36 

99 

195 

58 

April  11-15,  1901  .    . 
April  16-20,  1901  .    . 
April  21-25,  1901  .    . 
April  26-30,  1901  .    . 

.     38 
9 
3 
3 

Professor  Herbert  E.  Smith  made  a  careful  study  of 
this  epidemic,  and  found  that  it  was  unquestionably  due 
to  an  infection  of  one  of  their  sources  of  public  water- 
supply. 

The  water-supply  of  New  Haven  was  drawn  from  five 
distinct  systems.  It  was  all  surface  water,  and  was  used 
without  filtration.  One  of  these  sources  was  known  as 
the  Dawson  supply.  Dawson  Lake  was  a  storage 
reservoir  located  on  West  River  in  Woodbridge,  five 
miles  from  the  city.  It  had  an  area  of  60  acres,  and 
a  capacity  of  300,000,000  gallons.  The  watershed 
tributary  to  the  lake  had  an  area  of  13.6  square  miles, 
upon  which    there    was    no    direct    sewage    pollution. 


TYPHOID  FEVER  EPIDEMICS.  14I 

while  the  rural  population  amounted  to  only  25  per 
square  mile. 

A  mile  and  a  half  above  the  Dawson  dam  a  small 
stream  flowed  into  the  river,  and  about  half  a  mile 
up  this  stream  there  was  a  farmhouse  situated  at  an 
elevation  of  about  180  feet  above  the  water  in  the 
lake. 

During  January  and  February,  1901,  several  cases  of 
typhoid  fever  occurred  in  this  house.  The  excreta  were 
thrown  into  a  shallow  privy  vault  without  disinfection 
(for  the  reason  that  typhoid  fever  was  not  at  first  recog- 
nized), where  they  must  have  accumulated  and  remained 
more  or  less  frozen  for  six  weeks  or  more.  This  privy 
was  325  feet  from  the  brook  and  40  feet  above  it.  Dur- 
ing February  and  the  first  part  of  March,  the  weather 
was  steadily  cold;  but  on  March  10  and  11  there  was  a 
heavy  rainfall,  during  which  the  precipitation  was  2.46 
inches.  The  flow  was  so  large  that  in  spite  of  the  inter- 
vention of  the  storage  reservoir,  the  water  in  the  city  was 
in  a  turbid  condition  on  the  afternoon  of  March  11, 
As  the  typhoid  fever  outbreak  began  about  ten  days 
later,  there  seems  to  be  little  doubt  that  the  infection 
took  place  at  this  time. 

Professor  Smith  found  that  96  per  cent  of  the  cases 
that  occurred  were  in  the  district  supplied  with  water 
from  Dawson  Lake. 

In  the  course  of  his  studies  he  made  some  interesting 
comparisons  of  the  distribution  of  the  cases  by  ages,  which 
were  in  striking  contrast  to  those  found  in  the  Stamford 
epidemic  of  1895,  which  was  attributed  to  infected  milk. 
The  following  table  shows  these  percentages. 


142 


TYPHOID    FEVER. 


PER  CENTS  WHICH  THE  NUMBERS  OF  CASES  AT  CERTAIN 
AGES   WERE   OF   THE   TOTAL   NUMBER   OF   CASES. 


Ages. 

0-5- 

6-15. 

16-30. 

31-45. 

Over  45. 

Stamford  Epidemic  .... 
New  Haven  Epidemic      .    . 

% 

16.95 
8.10 

% 
48.19 
36-73 

% 
32.90 
49.66 

% 
14.76 

10-43 

% 
4-15 
3-i8 

The  Ithaca  Epidemic.  In  ihe  winter  of  1903,  Ithaca, 
N.Y.,  the  seat  of  Cornell  University,  was  visited  by  a 
severe  epidemic,  in  the  course  of  which  1350  cases  of 
typhoid  fever  occurred,  in  a  population  of  about  13,156. 
More  than  500  homes  were  visited,  and  there  were  82 
deaths.  The  epidemic  covered  a  period  of  about  three 
months,  and  extended  from  about  the  nth  of  January, 
1903,  to  the  first  of  April,  although  for  several  months 
before  the  epidemic  began,  typhoid  fever  had  been 
unduly  prevalent.  This  epidemic  was  carefully  studied 
by  Dr.  George  A.  Soper,  in  the  interest  of  the  New  York 
State  Department  of  Health. 

The  original  case,  or  cases,  which  gave  rise  to  the 
epidemic  were  not  ascertained,  but  that  the  disease  was 
due  to  the  public  water-supply  was  made  certain  by  the 
investigations  carried  on. 

Ithaca  had  at  that  time  three  separate  sources  of 
water-supply,  two  of  these  being  owned  by  the  Ithaca 
Water  Company,  and  the  third  by  Cornell  University. 
The  latter  supply,  however,  probably  had  little  or  nothing 
to  do  with  the  epidemic. 

Of  the  other  two  supplies,  the  larger  one  was  derived 
from  Six-mile  Creek,  which  had  a  drainage  area  of 
about  46  square  miles.     The  water  was  taken  from  a 


TYPHOID  FEVER  EPIDEMICS.  1 43 

small  reservoir  formed  by  damming  this  stream  below  the 
intake  crib,  and  pumped  into  a  reservoir  and  stand- 
pipe,  from  whence  it  flowed  by  gravity  to  the 
consumers.  The  second  supply  was  taken  from 
Buttermilk  Creek,  a  stream  which  drained  about  12 
square  miles. 

The  conditions  on  the  two  streams  were  similar. 
On  both  the  run-off  was  rapid,  and  the  flow  was 
subject  to  violent  fluctuations.  The  river  beds  were 
deeply  eroded  through  the  soil,  and  at  times  of  flood  the 
water  carried  a  large  amount  of  silt  in  suspension.  Both 
streams  were  considerably  polluted.  On  the  drainage 
area  of  Six-mile  Creek  there  dwelt  a  population  of  more 
than  2000,  about  forty  per  cent  of  which  lived  in  vil- 
lages bordering  on  the  creek.  The  nearest  of  these 
villages  to  the  waterworks  was  Brookton,  five  miles 
above  the  intake.  The  inspection  of  the  watershed 
showed  that  there  were  numerous  sources  of  contami- 
nation, and  that  even  in  the  city  of  Ithaca,  a  few  rods 
above  the  intake  of  the  waterworks,  there  were  no  less 
than  seventeen  privies  located  on  the  precipitous  banks 
of  the  creek.  It  is  known,  furthermore,  that  during  the 
year  previous  to  the  epidemic,  there  had  been  at 
least  six  cases  of  typhoid  fever  on  the  watershed. 

At  the  time  of  the  epidemic,  a  new  dam  was  being 
constructed  on  Six-mile  Creek,  a  short  distance  above 
the  water  works  intake.  One  theory  advanced  was  that 
the  excreta  from  a  possible  case  of  typhoid  fever  among 
these  laborers  may  have  caused  the  epidemic.  No 
proof  of  the  existence  of  such  a  case,  however,  was  found. 
Another  possible  source  was  a  gang  of  laborers  working 


144 


TYPHOID   FEVER. 


near  the  stream  three  miles  above  the  intake,  where  one 
of  the  party  was  known  to  have  had  the  disease.  Whether 
some  one  of  these  cases  or  some  unknown  case  was  the 
active  agent  in  causing  the  epidemic  was  not  determined, 
but  that  the  water  was  in  some  way  infected  cannot  be 
doubted. 

As  in  the  cases  of  Plymouth  and  New  Haven,  the 
typhoid  epidemic  in  Ithaca  followed  a  flood  in  the  river. 
During  the  month  of  December,  1902,  the  precipitation 
had  been  unusually  heavy.  General  rains  occurred  be- 
tween the  19th  and  2 2d,  and  there  were  heavy  rainfalls 
on  the  13th,  i6th,  and  21st. 

The  epidemic  began  about  the  nth  of  January, 
and  gradually  increased  in  severity  during  the  rest  of 
the  month.  On  some  days  more  than  30  new  cases 
were  reported.  The  following  figures  show  the  progress 
of  the  epidemic  by  weeks: 


New  Cases 

New  Cases 

Week  Ending  — 

Reported  by 

Week  Ending  — 

Reported  by 

the  Physicians.' 

the  Physicians.' 

January  17,  1902 

21 

February  28,  1902 

59 

January  24,  1902 

54 

March  7,  1902 

31 

January  31,  1902 

105 

March  14,  1902 

18 

February  7,  1902 

170 

March  21,  1902 

3 

February  14,  1902 

137 

March  28,  1902 

3 

February  21,  1902 

102 

'  The  actual  number  of  cases  was  larger  than  these  figures  would 
indicate,  as  not  all  were  reported. 

This  epidemic  occasioned  an  unusual  amount  of 
interest  by  reason  of  the  fact  that  the  town  included 
about  3000  students  in  Cornell  University.     Hundreds  of 


TYPHOID   FEVER  EPIDEMICS.  145 

the  students  left  town,  some  of  them  ill  with  the  disease. 
Some  of  them  probably  scattered  the  disease  elsewhere. 
The  effect  of  such  an  epidemic  is  far-reaching. 

One  episode  of  the  epidemic  is  worthy  of  special 
mention,  namely^  a  secondary  outbreak  which  resulted 
from  the  infection  of  a  well.  This  well  had  become 
popular  among  the  residents  of  a  certain  district  at  the 
time  when  the  public  supply  came  to  be  distrusted,  and 
its  good  quality  was  taken  for  granted.  But  the  wife  of 
the  owner  was  taken  sick  with  typhoid  fever  during  the 
epidemic,  and  her  dejecta  passed  without  disinfection 
through  the  water-closet,  and  into  a  drain-pipe  which  ran 
within  three  or  four  feet  of  the  well.  The  joints  of  the 
drain -pipe  were  insecure;  and  the  well  water,  which  had 
probably  been  for  some  time  grossly  contaminated, 
finally  became  infected.  As  a  result,  about  fifty  cases 
of  typhoid  fever  and  five  deaths  were  traced  to  people 
who  used  this  well  water. 

The  Scranton  Epidemic.  Scranton  is  a  coal-mining 
and  manufacturing  city  of  about  119,000  inhabitants 
in  the  eastern  part  of  Pennsylvania.  Until  December, 
1906,  it  had  had  a  fairly  satisfactory  typhoid  fever 
record.  The  water-supply  of  the  city  was  taken  chiefly 
from  impounding  reservoirs  on  Roaring  Brook,  south 
of  the  city,  and  delivered  to  the  city  by  gravity.  The 
main  storage  basin,  known  as  Elmhurst  Reservoir,  had 
a  capacity  of  about  1400  million  gallons,  or  nearly  50 
days'  supply.  From  it  the  water  flowed  through  an  open 
stream  several  miles  long,  to  what  is  known  as  No.  7 
Reservoir,  the  starting-point  of  the  city  mains.  No.  7 
Reservoir  had  a  capacity  of  about  100,000,000  gallons. 


146  TYPHOID    FEVER. 

and  the  distance  from  inlet  to  outlet  was  only  about 
2000  feet.  Provision  was  made  for  carrying  the  water 
direct  from  the  Elmhurst  Reservoir  to  the  city,  if  desired, 
without  passing  through  No.  7  Reservoir,  and  the  pipes 
were  so  arranged  that  any  excess  of  water  in  Roaring 
Brook  could  be  diverted  and  stored  in  Scranton  Lake, 
on  a  neighboring  watershed,  for  use  during  the  summer. 
The  Roaring  Brook  supply  in  1906  furnished  the 
greater  part  of  the  30  million  gallons  per  day  used  by 
the  city.  The  other  supplies,  also  impounded  surface 
waters,  were  not  concerned  in  the  epidemic,  and  need 
not  be  considered. 

Until  the  last  of  October,  1906,  the  Roaring  Brook 
water  was  delivered  to  the  city  by  allowing  it  to  flow 
through  the  No.  7  Reservoir,  but  at  that  time  this 
reservoir  was  cut  off,  and  the  water  was  furnished  direct 
from  Elmhurst,  being  taken  from  a  point  near  the  bottom. 

Although  thought  to  be  of  good  quality,  the  water- 
supply  was  open  to  contamination  at  various  points. 
Roaring  Brook  flowed  through  the  center  of  Moscow, 
a  village  of  about  eight  hundred  people,  only  a  mile 
above  Elmhurst  Reservoir,  and  the  borough  of  Elmhurst 
bordered  the  brook  below  the  reservoir.  The  main 
lines  of  the  Delaware,  Lackawanna  &  Western  Railroad 
crossed  and  recrossed  the  brook,  thus  offering  oppor- 
tunities for  contamination  with  excrement  dropped 
from  the  passenger  coaches  or  deposited  by  laborers 
along  the  track. 

In  some  way  or  other  the  Elmhurst  Reservoir  became 
infected  with  typhoid  bacilli  during  the  latter  part  of 
November,  1906,  but,  although  diligent  search  was  made 


TYPHOID  FEVER  EPIDEMICS. 


147 


by  the  State  Department  of  Health,  the  origin  of  the 
infection  was  not  discovered.  But  that  the  water 
was  infected  was  made  clear  by  the  statistics  of  the 
epidemic  and  by  the  analyses  which  were  made  of  the 
water.  ^ 

The  use  of  this  infected  water  gave  rise  to  an  epidemic 
which  extended  over  the  months  of  December,  January, 
and  February,  and  which  resulted  in  1155  reported 
cases  and  iii  deaths  during  this  time.  The  progress 
of  the  epidemic  is  shown  by  the  following  figures:       , 


Week  Ending  — 

Reported 
Typhoid  Cases. 

Week  Ending  — 

Reported 
Typhoid  Cases. 

December  8,  1906 
December  15,  1906 
December  22,  1906 
December  29,  1906 
January  5,  1907 

14 

70 

368 

269 

189 

January  12,  1907 
January  19,  1907 
January  26,  1907 
February  2,  1907 

74 

45 
36 
II 

The  epidemic  began  the  first  week  in  December,  1906. 
On  November  15,  there  had  been  a  heavy  snow-storm, 
and  this  was  followed  by  rains  on  the  i8th  and  21st, 
and  on  December  3,  6,  10,  and  15,  one  or  more  of  which 
may  have  been  the  means  of  washing  the  infectious 
matter  into  the  reservoir.  The  Elmhurst  water  was  shut 
off  on  December  15,  and  the  city  supplied  from  Lake 
Scranton;  and  soon  after,  the  epidemic  began  to  subside. 
The  typhoid  fever  in  the  city  occurred  almost  exclusively 
among  the  users  of  Elmhurst  water. 

Dr.    Wainright,    in    commenting    on    the    Scranton 

^  It  is  believed  that  in  at  least  one  sample  of  this  water,  the  typhoid 
bacillus  was  positively  identified. 


148 


TYPHOID    FEVER. 


epidemic,  refers  to   a  subject  which  is  too    often  over- 
looked.    He  says :  — 

"One  point  which  I  had  not  fully  appreciated,  and 
which,  I  think,  most  fail  to  appreciate,  is  that  typhoid 
is  to  a  certain  extent  a  directly  communicable  disease. 
The  Scranton  experience  has  impressed  this  on  me 
forcibly.  Thus,  there  were  54  families  in  which  there 
were  two  cases,  and  in  at  least  22  of  these  the  second 


110 

• 
100 

90 

CO  80 
u 

S70 
^60 

UJ 

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Z4O 

30 
20 
10 

1 

1 

'1 

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Mi 

iiii 

1     1 
j    1 

lilii,      1 

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Hi  vli 

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I'l 

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^v. 

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V^. 

^J'f^^-^A     A-AA 

A 

LJG. 

SEPT. 

OCT. 

NOV. 

DEC. 

JAN. 

DOTTED  LINE  REPRESENTS  CASES  DUE  TO  WATER  INFECTION 
FULL  LINE  REPRESENTS  CASES  DUE  TO  CONTAGION 


Fig.  12. 


Diagram  Showing  the  Progress  of  the  Typhoid  Epidemic  in  Gelsenkir- 
chen,  Germany. 

person  aflflicted  was  definitely  found  to  be  the  attendant 
to  the  patient.  There  were  7  families  which  had  three 
cases,  and  9  families  which  had  four  cases.  Among 
these  16  families  having  three  and  four  cases,  in  8  the 


TYPHOID  FEVER  EPIDEMICS.  1 49 

attendant  was  definitely  known  to  have  been  one  of  the 
secondary  cases.  An  interesting  fact  is  that  in  the 
families  where  more  than  one  case  occurred,  unusual 
numbers  of  the  secondary  cases  were  children.  For 
example,  in  the  three-  and  four-case  families,  out  of  35 
cases  for  which  I  have  data  as  to  age,  sixty  per  cent 
were  children." 

In  further  emphasis  of  this  point,  reference  may  be 
made  to  an  epidemic  of  typhoid  fever  in  Gelsenkirchen, 
Germany,  where  a  separation  of  the  contact  cases  from 
those  due  to  water  infection  was  carefully  made.  The 
relative  effect  of  the  secondary  cases  and  their  tardy 
occurrence  in  the  epidemic  is  shown  by  Fig.  12. 

One  discouraging  feature  of  the  Scranton  epidemic 
was  the  fact  that  its  existence  was  not  recognized  by  the 
health  department  until  it  was  well  under  way.  Wain- 
right  says  that  "it  was  the  chance  finding  of  a  reporter 
and  the  recognition  of  its  seriousness  by  an  editor  that 
prevented  further  fatal  delay." 

From  a  strictly  scientific  standpoint,  perhaps  the  most 
interesting  fact  about  this  epidemic  is  the  demonstration 
that  a  great  reservoir  holding  nearly  a  billion  and  a 
half  gallons  of  water  can  become  so  thoroughly  infected 
with  typhoid  bacilli  as  to  cause  an  epidemic  that  ex- 
tended over  a  period  of  several  weeks. 

The  Epidemics  of  Lowell  and  Lawrence.  During  the 
years  1 890-1 891  a  typhoid  fever  epidemic  occurred  in 
Lowell  and  Lawrence,  Mass.  As  this  epidemic  illus- 
trates better  than  almost  any  other  what  occurs  on 
streams  which  are  used  both  as  sources  of  water-supply 
and  as  receptacles  for  sewage,   it  deserves   more  than 


ISO 


TYPHOID    FEVER. 


passing  mention.  Both  cities  are  on  the  Merrimac 
River,  a  large  stream  flowing  through  New  Hampshire 
and  Northern  Massachusetts.  On  the  banks  of  the 
Merrimac  there  are  a  number  of  large  cities  and  towns, 
the  most  important  of  which  are  Concord  and  Nashua  in 
New  Hampshire,  and  Lowell,  Lawrence,  Haverhill,  and 
Newburyport  in  Massachusetts.  On  the  tributaries  of 
the  Merrimac  are  Fitchburg,  Clinton,  and  Marlboro. 
The  sewage  of  all  of  these  cities  finds  its  way  into  the 
river.  ^ 

The  water  of  the  river,  therefore,  was  subject  to  fecal 
contamination  throughout  its  course. 

The  epidemic  first  broke  out  in  Lowell  in  September, 
1890,  and  continued  for  about  five  months,  during  which 
new  cases  occurred  as  follows: 


Date. 


Cases  of 
Typhoid  Fever . 


September,  1890 
October,  i8go 
November,  i8go 
December,  1890 
January,      1891 


47 

95 

171 

159 
78 


550 


This  epidemic  was  studied  by  Professor  William  T. 
Sedgwick,  who  made  a  most  thorough  investigation. 
The    situation  was   complicated   by  the  fact  that   there 


'  In  1 890  these  cities  had  the  following  populations 
Lowell 77,696         Concord      .    . 


Lawrence  . 
Manchester 
Haverhill  . 
Nashua  .    . 


44,654 
44,126 
27,412 
19,311 


Fitchburg  .  . 
Newburyport 
Marlboro  .  . 
CUnton  .    .    . 


17,004 
22,037 
13.947 
13,805 
10,424 


TYPHOID  FEVER  EPIDEMICS.  151 

were  several  distinct  systems  of  water-supply  in  Lowell. 
The  principal  supply  of  the  city  was  taken  partly  from 
a  filter  gallery,  but  chiefly  from  the  Merrimac  River 
without  purification,  the  two  waters  being  mixed  and 
pumped  together  into  the  city  reservoirs.  The  second 
system  was  owned  by  the  Proprietors  of  Locks  and 
Canals,  and  was  used  chiefly  for  fire  purposes,  but  to 
some  extent  for  drinking.  The  supply  was  river  water 
taken  from  the  canal,  and  was  furnished  to  most  of  the 
mills.  There  was  a  third  system  also  taken  from  the 
canals  and  used  in  a  similar  way.  The  fourth  and  fifth 
supplies  were  driven  wells  and  spring  waters,  which  were 
considerably  used  on  account  of  the  disagreeable  quali- 
ties of  the  river  water.  Professor  Sedgwick's  investiga- 
tion resulted  in  tracing  the  infection  to  the  river  water, 
and  connected  the  beginning  of  the  epidemic  with  an 
outbreak  which  occurred  at  North  Chelmsford,  a  suburb 
of  Lowell,  where  there  were  several  cases  of  typhoid 
fever  in  houses  that  had  privies  overhanging  Stony 
Brook,  a  tributary  of  the  ]\Ierrimac  River. 

A  short  time  after  the  epidemic  in  Lowell,  typhoid 
fever  broke  out  in  Lawrence,  nine  miles  down  stream, 
and  rapidly  increased.  The  relation  between  these  two 
epidemics  was  most  striking.  Lowell  discharged  its 
sewage  into  the  river,  —  Lawrence  drank  the  water 
without  filtration.  The  water-supply  of  Lawrence  was 
consequently  infected  with  the  fecal  discharges  of  the 
typhoid  fever  patients  in  Lowell,  and  the  epidemic  followed 
as  an  inevitable  result.  The  relation  between  these  two 
epidemics  may  be  seen  from  the  following  figures: 


152 


TYPHOID    FEVER. 


Month. 


August,  1890  . 
September,  1890 
October,  1890  . 
November,  1890 
December,  1890 
January,  1891  . 
February,  1891 
March,  1891  . 
April,  1 89 1  .  . 
May,  1891     .    . 


Lowell. 


Number  of 
Deaths. 


28 
26 
19 
14 
10 
6 
4 


Death-rate 

per 

100,000. 


Lawrence. 


Number  of 
Deaths. 


3 
3 
7 

19 

19 

II 

6 

3 


Death-rate 

per 

100,000. 


2 .  24 
6-73 
6-73 
15-71 
42.64 
42.64 
24.  69 
13-46 

6-73 
4.49 


It  will  be  seen  from  these  figures  and  from  Fig.  13 
that  the  climax  of  the  Lawrence  epidemic  occurred  about 
one  month  after  that  in  Lowell. 

In  1892  there  was  a  repetition  of  this  epidemic. 
Typhoid  fever  in  Lowell  was  again  responsible  for  an 
increase  of  typhoid  fever  in  Lawrence.  The  situation 
was  not  as  serious  as  that  of  two  years  before,  but  this 
time  Newburyport  was  also  affected.  The  relation 
between  the  three  cities  is  shown  by  the  following  figures : 


Lowell. 

Lawrence. 

Newburyport. 

Date. 

1 

Cases. 

Deaths. 

Cases. 

Deaths. 

Cases. 

Deaths. 

November,  1892     .... 

19 

3 

14 

4 

0 

0 

December,  1892      .... 

70 

ID 

32 

9 

4 

I 

January,  1893 

3« 

10 

72 

3 

28 

3 

February,  1893  

14 

7 

23 

12 

9 

0 

March,  1893 

4 

4 

I 

TYPHOID  FEVER  EPIDEMICS. 


153 


It  is  said  the  reason  for  the  Newburyport  epidemic  was 
that  the  "  Newburyport  water  company  had  distributed 
to  the  cities  more  or  less  water  drawn  unpurified  directly 
from  the  Merrimac  River,  contrary  to  recent  specific  ad- 
vice of  the  danger  of  so  doing  addressed  to  them  by  the 
State  Board  of  Health,  and  referring  especially  to  the 


Fig.  13. 

Diagram  Showing  the  Chronological  Relation  between  the  Lowell  and 
Lawrence  Typhoid  Fever  Epidemics. 


likelihood  of  an  outbreak  of  typhoid  fever  if  they  should 
continue  to  do  so." 

In  justice  to  these  cities,  it  should  be  said  that  they 
now  have  safe  and  wholesome  water-supplies.  Lowell 
abandoned  the  river,  and  introduced  a  ground  water- 
supply,  while  at  Lawrence  a  filtration  plant  was  con- 
structed which  has  very  materially  reduced  the  amount 
of  typhoid  fever  in  that  city. 


154  TYPHOID   FEVER. 

The  Epidemics  of  Waterville  and  Augusta.  In  1902-3, 
an  epidemic  of  typhoid  fever  occurred  in  the  cities  of 
Waterville  and  Augusta,  Me.,  which  furnishes  an  inci- 
dent almost  parallel  to  the  Lowell  and  Lawrence  epidemic 
of  1890-1.  These  cities  are  situated  on  the  Kennebec 
River.  Augusta  is  the  capital  of  the  state,  and  Waterville, 
18  miles  up  the  river,  is  an  important  manufacturing  city. 

The  city  of  Waterville  was  supplied  with  water  from 
the  Messalonskee  system  by  the  Maine  Water  Company, 
which  also  furnished  water  to  the  neighboring  towns  of 
Fairfield,  Winslow,  and  Benton.  The  system  has  a 
watershed  of  205  square  miles,  and  drains  a  chain  of 
large  lakes.  The  population  on  the  watershed  was  27 
per  square  mile,  the  principal  source  of  pollution  being 
the  town  of  Oakland,  7  miles  above  the  pumping 
station,  where  the  population  was  about  2000. 

Waterville  discharged  its  sewage  into  the  Kennebec 
River.  Augusta,  at  this  time,  took  its  supply  from  the 
river  at  a  point  just  above  the  city  near  the  Kennebec 
dam.  The  water  was  pumped  to  a  reservoir  through 
an  old  Warren  filter,  one  of  the  first  of  its  kind  in  America. 
This  was  a  filter  only  in  name;  it  was  really  no  more  than 
a  strainer,  and  wholly  inefficient  in  removing  disease 
germs  from  the  water.  Augusta  discharged  its  sewage 
into  the  river. 

The  town  of  Richmond,  15  miles  below  Augusta,  also 
took  its  water  unpurified  from  the  Kennebec  River. 

The  epidemic  was  very  carefully  studied  by  the 
author,  assisted  by  Dr.  E.  C.  Levy  and  Mr.  Langdon 
Pearse,  in  connection  with  the  appraisals  of  the  water- 
works of  the  two  cities,  as  it  was  necessary  to  prove  in 


TYPHOID  FEVER  EPIDEMICS.  155 

court  the  probable  origin  of  the  trouble  and  its  connec- 
tion with  the  public  water-supplies.  In  fact,  it  was 
largely  due  to  these  epidemics  that  steps  were  taken  to 
transfer  the  ownership  of  the  works  from  the  private 
water  companies  to  the  water  districts,  which  represented 
the  people. 

The  epidemic  was  first  noticed  at  Waterville,  in 
November,  1902.  For  about  a  month  new  cases  were 
reported  at  the  rate  of  one  a  day.  On  Christmas  Day 
there  were  five  new  cases,  and  during  the  next  week  the 
daily  number  of  cases  was  about  the  same.  Thirteen 
were  reported  on  New  Year's  Day.  After  the  middle 
of  January  the  number  of  new  cases  fell  off,  but  they 
continued  to  be  reported  at  intervals  until  March.  In 
Fairfield,  Winslow,  and  Benton,  typhoid  fever  occurred 
at  the  same  time.  The  largest  number  of  cases  was 
reported  during  the  first  two  weeks  of  January.  These 
four  communities  had  the  same  water-supply,  namely, 
that  oi  the  Messalonskee  River,  and  from  the  first  it  was 
evident  that  this  was  the  cause  of  the  epidemic. 

As  the  sewage  of  these  typhoid-fever-stricken  communi- 
ties emptied  into  the  Kennebec  River,  and  as  the  water 
of  this  river  furnished  the  supply  of  Augusta,  it  was  almost 
inevitable  that  the  epidemic  should  extend  to  that  city 
also,  and  this  is  what  actually  occurred.  During  the 
latter  part  of  November  and  the  whole  of  December 
new  cases  of  typhoid  fever  occurred  daily  in  Augusta. 
It  seems  probable  that  these  earlier  cases  were  due  to 
the  same  source  of  infection  that  caused  the  epidemic 
at  Waterville,  inasmuch  as  the  Messalonskee  River, 
which  supplied  that  city,  discharged  into  the  Kennebec 


156  TYPHOID    FEVER. 

above  Augusta.  It  was  not  until  about  two  weeks  after 
the  climax  of  the  Waterville  epidemic  that  the  serious 
period  of  the  Augusta  epidemic  began.  During  the 
latter  part  of  December  and  throughout  the  months  of 
January  and  February  the  sewage  at  Waterville  must 
have  been  infected  with  typhoid  fever  bacilli;  and,  making 
due  allowances  for  the  periods  of  sickness,  transmission, 
and  incubation,  this  time  corresponded  with  the  duration 
of  the  epidemic  at  Augusta.  After  the  Waterville  epidemic 
had  ceased  and  sufficient  time  had  elapsed  for  the  patients 
to  recover,  the  epidemic  at  Augusta  came  to  an  end. 

At  Richmond,  which  is  only  a  small  village,  typhoid 
fever  did  not  occur  until  the  middle  of  January;  but 
occasionally  cases  appeared  during  the  next  two  or  three 
months,  and  were  plainly  connected  with  the  epidemic  of 
the  cities  above. 

Fig.  14  shows  chronologically  the  progress  of  this 
epidemic,  together  with  certain  factors  which  affected 
it.  It  indicates  that  the  epidemics  in  the  different  com- 
munities formed  a  connecting  series,  and  may  be  really 
considered  as  one  epidemic,  inasmuch  as  they  started 
from  a  common  cause.  In  all  there  were  about  612 
cases  and  53  deaths. 

The  epidemic  at  Waterville  was  traced  to  two  cases  of 
typhoid  fever  which  occurred  on  the  watershed  above 
the  intake.  The  first  of  these  was  at  the  city  alms- 
house located  in  the  suburbs  of  Waterville  only  a  few 
hundred  feet  from  the  stream.  On  September  22,  1902, 
a  typhoid  fever  patient  was  admitted  to  the  almshouse. 
His  attack  was  a  mild  one,  and  he  was  confined  to  his 
bed  for  only  a  week;  but  after  leaving  his  bed  he  remained 


AUGUSTA    WATER  DISTRICT 


TYPHOID  FEVER  EPIDEMICS.  1 57 

five  days  at  the  almshouse,  and  during  this  latter  period 
no  attempt  was  made  to  disinfect  either  his  excreta  or 
urine,  which  were  deposited  sometimes  in  a  privy  in  the 
yard,  and  sometimes  in  a  water-closet  which  drained 
into  a  cesspool  on  the  premises.  On  November  6,  both 
the  privy  and  cesspool  were  cleaned  and  their  contents 
spread  upon  the  almshouse  garden,  the  ground  being 
frozen  at  this  time.  The  slope  of  the  garden  was 
towards  the  river. 

The  second  case  occurred  about  a  mile  outside  of 
Waterville,  in  the  family  of  a  milkman.  During  1902 
there  had  been  five  cases  of  typhoid  fever  in  this 
house.  In  all  of  these  cases  except  one,  a  prompt  diag- 
nosis had  been  made,  and  the  dejecta  were  properly 
disinfected  and  buried,  but  in  one  case  the  patient  was 
ill  for  several  weeks  before  the  diagnosis  was  made. 
During  this  time,  i.e.,  from  September  ist  to  25th,  1902, 
disinfection  was  not  practiced,  and  the  stools  were 
emptied  into  the  privy  vault.  Early  in  November  the 
privy  was  cleaned  and  the  contents  deposited  on  a  field 
away  from  the  house  at  a  point  where  the  land  sloped 
abruptly  towards  a  brook  200  feet  distant,  this  brook 
being  tributary  to  the  Messalonskee  Stream  three-quarters 
of  a  mile  away.  Both  the  almshouse  and  the  mouth  of 
this  stream  were  about  one  mile  distant  from  the  water- 
works intake. 

Thus,  early  in  November,  1902,  typhoid  fever  dejecta 
had  been  deposited  upon  the  surface  of  frozen  ground  at 
two  points  relatively  near  the  pumping  station.  During 
November  and  the  first  part  of  December  the  rainfall 
was  light,  and  there  was  some  snow,  but  apparently 


15^  TYPHOID    FEVER. 

during  this  time  small  amounts  of  infectious  matter 
were  washed  into  the  stream.  On  the  i6th  of  December 
there  was  a  heavy  rain,  and  nine  days  later,  on  Christmas 
Day,  the  main  epidemic  began.  The  heaviest  rainfall, 
after  the  infectious  material  was  deposited  on  the 
fields  occurred  on  December  22,  with  a  precipitation 
amounting  to  1.3  inches.  Ten  days  after  this,  or  almost 
exactly  the  same  interval  as  after  the  rainfall  of 
December  16,  there  developed  the  greatest  number 
of  cases  of  any  which  occurred  during  the  epidemic. 
Throughout  the  two  months,  from  the  last  third  of 
November  until  the  corresponding  time  in  January, 
the  relation  between  the  rainfall  in  typhoid  fever  cases 
was  manifest.  About  the  middle  of  January  the  typhoid 
bacilli  had  either  lost  their  vitality,  or  had  been  washed 
away,  as  subsequent  heavy  rainfalls  were  not  followed 
by  serious  consequences. 

Profiting  by  their  experience,  the  cities  of  Waterville 
and  Augusta  have  both  abandoned  the  use  of  the  river 
water,  and  now  take  their  suppHes  from  lakes  at  a  con- 
siderable distance  from  the  city. 

The  Pittsburg  and  Allegheny  Epidemics.  For  many 
years  the  cities  of  Pittsburg  and  Allegheny,  Pa.,  have 
been  in  the  throes  of  a  typhoid  fever  epidemic  which 
has  spread  its  baneful  influences  over  the  western  part 
of  the  state,  and  scattered  the  disease  even  more  widely 
through  the  agency  of  many  an  unfortunate  visitor  and 
traveling  man.  It  is  one  of  the  black  records  in  the 
sanitary  history  of  our  country. 

These  two  cities  are  situated  at  the  confluence 
of    the    Allegheny    and  Monongahela    Rivers,  —  where 


TYPHOID  FEVER  EPIDEMICS.  1 59 

they  unite  to  form  the  Ohio  River.  In  1900  Pitts- 
burg had  a  population  of  321,616,  and  Allegheny 
129,896. 

Pittsburg  takes  its  water  from  the  Allegheny  River 
at  Brilliant  Station,  six  miles  above  the  junction  of  the 
rivers,  and  from  the  Monongahela  River,  at  a  point 
three  miles  above  the  junction.  The  first-named  supply 
is  under  municipal  control,  and  furnishes  about  three- 
quarters  of  the  supply  delivered  between  the  rivers  in 
Wards  i  to  23.  The  second  is  operated  by  a  private 
company,  and  supplies  Wards  24  to  36,  south  of  the 
Monongahela  River.  In  neither  case  is  the  water  puri- 
fied, and  the  period  of  storage  in  the  distribution  reser- 
voir is  inconsiderable.  Both  rivers  are  contaminated  by 
the  sewage  of  large  communities,  some  of  them  only  a 
few  miles  from  the  city.  The  water  is  at  times  muddy 
and  disagreeable.  The  urban  population  in  1900  was 
28  per  square  mile  on  the  Allegheny  River,  and  26  per 
square  mile  on  the  Monongahela. 

The  statistical  data  showing  the  occurrence  of  typhoid 
fever  are  given  elsewhere  in  this  volume,  so  that  in  this 
connection  it  is  only  necessary  to  state  that  in  this 
unfortunate  city  there  occur  annually  upwards  of  5000 
cases  of  the  disease.  It  is  scattered  all  over  the  city, 
but,  on  the  whole,  the  wards  supplied  with  Allegheny 
water  suffer  the  most.  It  is  present  at  all  seasons,  but 
is  more  prevalent  in  the  fall  and  winter  months  than  in 
cities  supplied  with  good  water. 

The  Pittsburg  case  is  instructive,  as  it  illustrates  the 
dangers  of  procrastination.  Ten  years  ago  and  more,  it 
was  known  that  the  public  water-supplies  were  infected. 


i6o 


TYPHOID    FEVER. 


Fig.  15. 


TYPHOID   FE\^ER   EPIDEMICS.  l6l 

The  best  methods  of  filtering  the  supply  were  determined 
in  1898  by  an  elaborate  series  of  experiments.  Delays 
followed,  and,  although  a  filter  plant  is  now  under  con- 
struction and  nearly  completed,  it  is  not  yet  ready  for 
use.^  The  delay  has  cost  the  city  at  least  2000  lives, 
—  possibly  3000,  —  and  has  brought  unnecessary  sick- 
ness into  more  thousands  of  homes. 

The  case  of  Allegheny  is  equally  bad.  The  water- 
supply  is  taken  from  the  Allegheny  River  at  Montrose, 
10  miles  from  the  Point,  and  is  drawn  from  a  rock- 
filled  crib.  It  is  practically  unfiltered  water,  grossly 
contaminated.  Allegheny  is  smaller  than  Pittsburg,  but 
its  typhoid  fever  death-rate  has  been  even  higher. 

These  communities  have  been  singled  out  for  comment 
not  because  they  are  the  only  instances  of  epidemics 
due  to  long-continued  contamination  of  the  water-supply, 
or  because  they  are  the  only  cities  which  have  failed  to 
live  up  to  the  light  within  them.  Philadelphia  has  been 
equally  culpable,  and  other  cities  might  be  named. 
Pittsburg,  however,  is  a  very  clear-cut  case. 

The  Chicago  Epidemic.  Chicago,  the  second  largest 
city  in  the  United  States,  situated  on  Lake  Michigan, 
had  for  many  years  a  water-supply  that  was  constantly 
being  contaminated  with  the  discharges  of  her  own  sewers. 
The  water  was  taken  from  the  lake  opposite  the  city 
at  several  "cribs,"  which  were  1.5  to  4  miles  off  shore. 
Sewers  were  discharged  all  along  the  water-front;  while 
the  Chicago  River,  penetrating  the  city  with  its  north 
and  south  branches,  and  polluted  almost  beyond  endur- 
ance, flowed  into  the  lake  about  midway  between  the 

^(January,  1908.) 


1 62  TYPHOID    FEVER. 

upper  and  lower  cribs.  That  intense  pollution  of  the 
lake  water,  and  hence  of  the  water-supply  of  the  city, 
resulted  from  this  situation  was  well  known.  It  needed 
no  elaborate  studies,  for  at  times  the  foul  river  water 
could  be  traced  to  the  intakes  with  the  eye. 

This  intolerable  situation  resulted  in  the  building  of 
the  Chicago  Drainage  Canal,  the  object  of  which  was 
to  take  the  sewage  out  of  the  lake  and  carry  it  westward 
down  the  DesPlaines  and  Illinois  rivers  into  the 
Mississippi,  —  a  project,  recently  consummated,  which 
has  given  rise  to  some  important  litigation  before  the 
United  States  Supreme  Court  between  the  states  of 
Missouri  and  Illinois.  By  the  construction  of  this 
canal  the  flow  of  the  Chicago  River  was  reversed, 
so  that,  instead  of  the  sewage  entering  the  lake  and 
polluting  the  water-supply,  the  water  of  Lake  Michigan 
with  the  greater  part  of  the  sewage  now  flows  westward 
to  the  Mississippi  and  to  the  Gulf  of  Mexico.  What- 
ever the  effect  of  this  has  been  on  the  cities  along  the 
Illinois  and  Mississippi  rivers,  this  canal  has  improved 
the  water-supply  and  reduced  the  amount  of  typhoid 
fever  in  Chicago. 

As  an  illustration  of  an  epidemic  caused  by  contam- 
inated lake  water,  the  Chicago  situation  during  the 
years  1890,  1891,  and  1892  affords  an  important  example. 
Within  one  fatal  year  nearly  2400  of  the  inhabitants 
died  from  typhoid  fever,  and  these  deaths  probably 
represented  at  least  25,000  cases.  The  following  figures 
show  the  number  of  deaths  each  month: 


TYPHOID  FEVER  EPIDEMICS. 


163 


Month. 


Deaths  from  Typhoid  Fever. 


1890. 


1892. 


January    .  . 

February  .  . 

March  .    .  . 

April.    .    .  . 
May  .... 

June     .    .  . 

July  .    .    .  . 

August      .  . 

September  . 

October    .  . 

November  . 

December  . 

Total 


53 
136 

103 

45 

82 

107 


"5 
95 

72 
67 
47 

1008 


67 
61 

71 

136 
408 
167 

200 
182 


171 

150 


311 

187 

76 

56 

70 

55 

211 
179 
138 

92 
67 
47 


1997 


Although  typhoid  fever  had  been  very  abundant  in 
1890,  the  greatest  period  of  the  epidemic  began  in 
April,  1 89 1.  It  continued  without  a  break  for  nearly 
a  year;  then  came  a  decrease,  and  then  for  several 
months  the  deaths  increased  again. 

Epidemics  due  to  lake  pollution  are  quite  likely  to  be 
of  long  duration,  for  the  reason  that,  as  the  epidemic 
increases  in  severity,  the  sewage  of  the  city  becomes  more 
and  more  infected,  and  this  increases  the  number  of 
typhoid  bacilli  in  the  water.  Such  an  epidemic  tends 
to  perpetuate  itself,  and  may  continue  until  all  susceptible 
persons  have  had  the  disease,  or  until  the  conditions 
of  winds,  currents,  etc.,  are  such  that  for  a  time  the 
contamination  of  the  water  ceases. 

In  1902   another   epidemic   occurred   in    Chicago,  — 


164 


TYPHOID    FEVER. 


CHICAGO,  ILL. 

DIAGRAM  SHOWING  THE 

POPULATION 

NUMBER  OF  DEATHS  FROM 

TYPHOID  FEVER 

AND  THE 

TYPHOID  DEATH   RATES 

BY  YEARS. 


1000 


Fig.  16. 


TYPHOID  FEVER  EPIDEMICS.  1 65 

less  in  magnitude  than  the  one  just  described,  but  yet 
one  which  caused  the  annual  number  of  deaths  to 
increase  from  337  in  1900,  to  509  in  1901,  and  801  in 
1902.  This  epidemic  came  as  a  surprise  to  many  of 
the  citizens  of  Chicago,  as  they  had  been  led  to  believe 
that  the  new  drainage  canal  would  effectually  act  as  a 
safeguard  to  the  water-supply.  But  the  explanation 
was  obvious.  Although  the  drainage  canal  was  opened 
in  1900,  not  all  of  the  sewers  had  been  connected  with 
it,  —  the  intercepting  sewer  along  the  south  shore,  and 
the  Lawrence  Avenue  sewer  on  the  north  side,  for  example, 
had  not  been  completed,  —  so  that  a  considerable  part 
of  the  city  continued  to  discharge  its  sewage  into  the 
lake.  The  epidemic  began  early  in  the  summer. 
The  193  persons  who  died  in  August  probably  contracted 
the  disease  in  June  or  July.  It  was  noticed  that  the 
rainfall  during  May,  June,  and  July  of  that  year  had 
been  exceptionally  heavy,  —  larger,  in  fact,  than  for  any 
corresponding  period  since  the  epidemic  of  1892.^ 

At  most  times  the  typhoid  fever  records  of  the  city 
show  a  general  correspondence  between  the  rainfall  and 
the  occurrence  of  typhoid  fever,  although,  as  might  be 
expected,  this  relation    has  not   been  quite   as  marked 


Year  Rainfall  during  May,  June,  and  July. 

1892 19-58 

1893 

1894 5- 

189s 5- 


1897   •    •    ■ 5 

1898 9 

1899 13 

1900 10 

1901 , 8 

1902   ................:....  17 


1 66  TYPHOID    FEVER. 

since  the  drainage  canal  was  put  in  service  as  it  was 
before.  The  annual  report  of  the  Department  of 
Health  for  1906  refers  to  the  low  rainfall  of  that  year 
as  one  reason  for  a  reduced  typhoid  death-rate. 

Recently  the  typhoid  death-rate  in  Chicago  has  been 
lower  than  formerly;  but  from  the  nature  of  the  sanitary 
conditions  along  the  water-front,  and  the  inevitable 
contamination  of  the  water  resulting  from  shipping 
and  other  causes,  there  is  no  reason  to  expect  that  the 
city  will  ever  have  a  permanently  low  typhoid  death- 
rate  until  the  lake  water  is  filtered. 

The  Cleveland  Epidemic.  Another  instance  of  an 
epidemic  caused  by  contaminated  lake  water  is  that  of 
Cleveland,  Ohio. 

The  city  of  Cleveland  is  situated  on  an  indentation  in 
thC' southern  shores  of  Lake  Erie,  about  two-thirds  of  the 
way  from  Toledo  to  Buffalo.  This  indentation,  or 
bay,  is  about  40  miles  long  and  7  miles  wide,  and  within 
it  the  water  is  nowhere  deeper  than  60  feet.  The 
Cuyahoga  River  flows  into  the  lake  through  the  heart 
of  the  city. 

The  water-supply  of  the  city  is  derived  entirely  from 
the  lake.  The  old  intake,  which  was  used  until  1904, 
was  located  about  i|  miles  from  the  shore  and  i  mile 
west  of  the  mouth  of  the  river,  the  water  being  taken  at 
depths  of  12  to  28  feet  below  the  surface,  and  conveyed 
by  two  tunnels  to  the  pumping  station  at  Division  Street. 
In  order  to  supply  a  greater  quantity  of  water,  and  at  the 
same  time  to  secure  water  of  a  better  quality,  new  works 
were  begun  in  1890  and  completed  in  1904.  The  new 
intake  is  located  4  miles  from  the  shore,  almost  opposite 


TYPHOID  FEVER  EPIDEMICS.  1 67 

the  mouth  of  the  Cuyahoga  River.  From  the  steel  crib 
a  9-foot  tunnel  conveys  the  water  to  a  pumping  station 
on  the  shore  of  the  lake  at  Kirtland  Street. 

All  of  the  sewage  of  the  city  flows  directly  or  indirectly 
into  the  lake.  About  one-half  of  it  flows  into  the  Cuya- 
hoga River,  and  the  rest  empties  directly  into  the  lake 
along  the  water-front.  It  has  been  estimated  that  the 
amount  of  solid  matter  discharged  into  the  lake  through 
these  sewers  amounts  to  100  tons  a  day,  while  the 
number  of  bacteria  contained  in  it  amounts  to  more  than 
100  million  billion.  These  figures  are  incomprehensible, 
and  mean  little  except  when  taken  in  connection  with 
the  subject  of  dilution.  Beside  the  pollution  from  the 
river  and  the  sewers,  the  water-supply  of  the  city  was 
at  that  time  endangered  by  the  practice  of  dumping 
dredged  material  from  the  river  at  points  dangerously 
near  the  intakes. 

During  the  year  1903,  when  the  water-supply  was 
drawn  wholly  from  the  old  intake,  a  severe  epidemic 
broke  out  in  the  city.  This  continued  throughout  the 
entire  year,  and  extended  over  the  spring  months  of 
1904,  ending  only  with  the  introduction  of  water  from  a 
new  source. 

In  order  to  understand  the  course  of  this  epidemic,  it 
is  necessary  to  know  that  under  ordinary  conditions 
the  Cuyahoga  River  water  and  the  sewage  of  the  city 
become  so  thoroughly  mixed  and  diluted  with  the  water 
of  the  lake  that  the  effect  of  contamination  is  not  serious 
a  mile  or  two  out  from  the  shore,  but  that  at  times  of 
heavy  rains  which  cause  floods  in  the  river,  and  especially 
at  those  times  when  the  floods  occur  in  connection  with 


1 68  TYPHOID    FEVER. 

an  off-shore  wind,  pollution  reaches  the  old  intake  crib 
in  such  quantities  as  to  grossly  contaminate  the  water- 
supply.  A  study  of  the  typhoid  data  prior  to  1903 
showed  that  after  severe  southeasterly  storms  there  was 
likely  to  be  an  increase  of  the  disease  in  the  city. 
The  investigations  made  in  connection  with  the  epidemic 
referred  to  showed  that  at  the  point  where  the  new  intake 
was  located,  4  miles  off  the  shore,  the  influence  of  the  city 
sewage  on  the  lake  water  was  extremely  slight,  although, 
even  at  that  distance,  there  were  times  when  traces  of  it 
could  be  detected. 

The  epidemic  of  1903  began  on  January  6,  when  9 
new  cases  were  reported.  Ten  days  before  this  there 
had  been  a  heavy  rainfall  which  increased  the  discharge 
of  the  river,  and  which  was  followed  by  fresh  south- 
easterly winds. 

It  is  unnecessary  to  explain  here  all  the  fluctuations 
in  the  typhoid  morbidity  which  occurred  during  this 
year,  but  the  data  show  that  the  wind  exerted  the  con- 
trolling influence  on  the  typhoid  fever  in  the  city. 
(See  Fig.  17.)  During  the  year  1903  the  total  num- 
ber of  cases  reported  was  3443,  and  there  were  472 
deaths. 

The  severest  part  of  the  epidemic  occurred  early  in 
1904,  beginning  after  a  memorable  flood  on  January  20, 
21,  and  22. 

On  these  three  days  the  rainfall  aggregated  2.57 
inches,  while  the  wind  blew  strongly  from  the  south- 
east. Moreover,  on  the  day  preceding  this  storm  the 
southeasterly  wind  movement  had  been  515  miles.  On 
January  21,  the  discharge  of  the  Cuyahoga  River  was 


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TYPHOID  FEVER  EPIDEMICS. 


169 


Fig.  18. 


I/O  TYPHOID    FEVER. 

very  great,  and  immense  quantities  of  mud  were  carried 
into  the  lake,  possibly  200,000  cubic  yards,  or  more 
than  is  ordinarily  discharged  during  an  entire  year. 
On  January  31,  ten  days  after  this  flood,  typhoid  fever 
began  to  increase  in  the  city,  and  this  increase  continued 
until  February  10,  when  25  new  cases  were  reported  in 
one  day.  On  February  6  and  7,  there  was  another 
southeasterly  storm  which  caused  a  flood  in  the  river. 
Although  the  stream  discharge  was  less  than  before,  the 
sewage  of  the  city  had  become  so  thoroughly  infected 
that  the  amount  of  typhoid  in  the  city  increased  more  than 
before.  A  week  of  calm  weather  followed,  and  the 
amount  of  typhoid  fever  in  the  city  dropped  off.  On  the 
13th  and  14th  of  February  there  was  another  strong 
southeast  wind,  and  ten  days  afterward  the  morbidity 
rate  rose  again,  and  so  the  epidemic  continued,  until 
a  change  came  in  the  source  of  supply. 

During  the  16  months  from  January,  1903,  until  May, 
1904,  there  were  4578  cases  of  typhoid  fever  reported  to 
the  Health  Department,  and  611  deaths. 

The  introduction  of  water  from  the  new  intake  occurred 
gradually.  The  Kirtland  Street  station,  where  water 
was  taken  from  the  new  intake,  was  started  on  February 
10,  1904,  and  the  pumps  at  the  Division  Street  station, 
the  old  supply,  were  finally  shut  down  on  April  7. 
Between  these  two  days,  water  was  drawn  from  both 
intakes.  As  the  proportion  of  water  from  the  new 
intake  increased,  the  typhoid  fever  in  the  city  began  to 
disappear,  and  finally,  after  the  old  supply  had  been 
entirely  abandoned,  the  epidemic  ceased.  The  following 
figures  show  the  close  relation  between  this  change  in  the 


TYPHOID  FEVER  EPIDEMICS. 


171 


character  of  the  water-supply  from  bad  to  good,  and  the 
decrease  in  the  typhoid  fever. 


Period. 

Average  Number 

of  New  Cases  of 

Typhoid  Fever 

Reported  Daily. 

January  i,  to  January  31,1904:   Period  prior  to  the 
epidemic  caused  by  flood 

February  i  to  March  5:    Period  of  epidemic  corre- 
sponding to  exclusive  use  of  old  supply 

March  6  to  March  15 :  Period  of  epidemic  correspond- 
ing to  use  of  one-half  of  supply  from  new  intake  and 

2.84 
20.91 

II.  10 

March  16  to  April  21 :  Period  of  epidemic  correspond- 
ing to  use  of  three-quarters  of  supply  from  new 
intake      .            

2.89 

April  22  to  December  31:    Period  corresponding  to 
exclusive  use  of  water  from  new  intake 

1.03 

The  Burlington  Epidemics.  The  city  of  Burlington, 
Vermont,  is  located  on  Lake  Champlain.  In  1866  it 
introduced  a  water-supply,  taking  the  water  from  the 
lake  at  one  of  the  docks  near  the  city  where  the  pumping 
station  was  located.  Somewhat  later,  sewers  were 
built  which  discharged  into  the  lake  less  than  half 
a  mile  away  from  the  waterworks  intake;  but  in  1885, 
on  account  of  excessive  pollution,  the  outfall  sewer 
was  removed  to  a  distance  of  one  mile.  This,  however, 
did  not  relieve  the  situation,  and  typhoid  fever  and  other 
forms  of  diarrheal  diseases  were  prevalent  until  1894, 
when  the  waterworks  intake  was  extended  two  miles 
and  a  half  into  the  lake  to  a  point  near  Appletree  Island. 


172 


TYPHOID    FEVER. 


After  this  change  in  the  supply  there  was  a  reduction  of 
typhoid  fever  in  the  city;  but  during  the  last  ten  years, 
the  death-rates  have  shown  a  tendency  to  increase,  while 


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old  intake  at  dock  new  intake  2j^  miles  out 

Fig.  19. 

Diagram  Showing  the  Relation  between  the  Water-Supply  and  the 
Typhoid  Fever  Death-rates  at  Burlington,  Vt. 

the  diarrheal  diseases  have  remained  prevalent.  In 
consequence  of  this  continued  pollution,  which  comes 
partly  from  the  city  itself,  and  partly  from  towns  drain- 


TYPHOID  FEVER  EPIDEMICS.  1 73 

ing  into  the  Winooski  River,  which  enters  the  lake  not 
far  away,  the  city  decided  in  1907  to  build  a  filter  plant. 
This  is  now  under  construction/ 

The  Butler  Epidemic.  Butler,  Pa.,  is  a  borough  in  the 
western  part  of  the  state  fifty  miles  north  of  Pittsburg. 
In  1903,  when  the  epidemic  occurred,  it  had  a  popula- 
tion of  about  16,000.  The  water-supply  was  taken  from 
a  reservoir  on  the  Connoquenessing  Creek,  filtered  and 
pumped  into  the  city  mains.  Originally,  the  water 
had  been  taken  directly  from  the  creek,  and  the  old 
connection  remained.  The  creek  at  this  point  was 
subject  to  certain  gross  pollutions,  and  this  was  the 
occasion  for  constructing  a  reservoir  at  Boydstown, 
seven  miles  above  Butler,  and  a  second  reservoir  on 
Thorn  Run.  The  filter  plant  was  a  mechanical  filter 
of  the  "pressure"  type.  Carefully  operated,  it  was 
fairly  efficient,  but  it  cannot  be  compared  in  efficiency 
to  one  of  our  modern  gravity  filter  plants. 

In  the  course  of  some  alterations  that  were  being 
made  in  the  pipe  connections  at  the  pumping  station, 
this  filter  plant  was  put  out  of  service  between  October 
20  and  31,  1903;  and  because  of  the  failure  of  the 
dam  of  the  Boydstown  reservoir  on  August  27,  water 
was  being  drawn  at  this  time  from  the  old  intake,  — 
that  is,  directly  from  the  creek,  and  close  to  the  borough 
limits. 

Ten  days  after  the  filter  was  shut  down,  —  that  is,  dur- 
ing the  first  week  of  November,  —  the  epidemic  broke 
out  in  all  parts  of  the  borough.  It  increased  in  severity 
and  continued  for  several  weeks.     Between  November  i 

^  January,  1908. 


174  TYPHOID    FEVER. 

and  December  17,  1903,  there  were  1270  cases  and  56 
deaths. 

Dr.  George  A.  Soper,  who  made  a  careful  study  of  the 
epidemic,  secured  information  regarding  several  cases 
of  typhoid  fever  which  had  occurred  on  the  watershed,  — 
some  of  them  within  half  a  mile  of  the  pumping  station 
and  above  the  intake,  and  others  near  a  brook  that 
enters  the  creek  within  100  feet  of  the  filter  plant.  The 
creek  water,  therefore,  had  ample  opportunities  for 
infection.  The  filter  had  been  the  only  protection  to  the 
water  consumers  during  the  summer,  and  the  withdrawal 
of  this  protection  led  to  the  epidemic. 

In  a  certain  sense  the  Butler  epidemic  may  be  called 
an  "accidental  one,"  yet,  in  view  of  the  known  pollution 
of  the  creek,  it  is  difficult  to  see  how  the  exigencies 
of  the  case  could  have  justified  the  temporary  shutting 
down  of  the  filter.  It  was  certainly  done  at  great  risk, 
and  the  result  carries  with  it  a  lesson  that  should  be 
heeded. 

The  Butler  waterworks  were  owned  and  operated 
by  a  private  company;  and  the  question  has  been  asked 
more  than  once,  —  "Would  such  a  risk  have  been 
assumed  if  the  works  had  been  operated  under  municipal 
ownership?"     It  is  an  interesting  question. 

The  Lowell  Epidemic  of  1902.  Since  1896  the  city 
of  Lowell,  Mass.,  has  been  supplied  with  driven-well 
water,  and  the  amount  of  typhoid  fever  in  the  city  has 
been  comparatively  low. 

In  August,  1903,  there  was  a  sudden  increase  of  typhoid 
fever,  as  shown  by  the  following  statistics: 


TYPHOID   FEVER  EPIDEMICS. 


175 


TYPHOID    FEVER    STATISTICS    BY    WEEKS    AT    LOWELL, 
MASS.,   IN   SUMMERS   OF    1901,    I902,   AND    1903. 


1901- 

1902. 

1903. 

Week 
Ending— 

Cases. 

Deaths. 

Week 
Ending  — 

Cases. 

Deaths. 

Week 
Ending  — 

Aug.     I 
"        8 

"      IS 
"      22 
"      29 

Sept.    5 
"      12 

"     19 
"     26 

Cases. 

Deaths. 

Aug.     3 
"      10 

"      17 
"      24 

"      31 

Sept.    7 

"     14 
"     21 
"     28 

0 

I 
0 
I 
4 

3 
I 

I 
2 

13 

0 
0 
0 
0 
0 

0 
I 
0 
0 

Aug.      2 

"        9 
"      16 
"      23 
"      30 

Sept.    6 

"     13 
"     20 
"     27 

2 

I 
0 
2 
0 

4 
I 
2 
3 

IS 

0 

I 
I 
0 
1 

2 
0 
0 

I 

6 

0 

0 

13 

7S 

41 

20 

7 
8 

4 

I 
0 
0 

I 
I 

2 
2 
2 

0 

Total 

I 

168 

9 

During  these  two  months  there  were  168  reported 
cases,  as  compared  with  13  cases  in  1901,  and  15  cases 
in  1902,  during  similar  periods.  The  outbreak  was 
traced  to  a  pollution  of  the  water-supply  of  the  city  mains 
in  the  following  manner: 

The  cotton  mills  of  the  city  had  a  water-supply  of  their 
own  derived  from  the  Merrimac  and  used  for  fire  pro- 
tection. This  system  had  several  connections  with  the 
public  supply  of  the  city,  controlled  by  check  valves; 
and  the  arrangement  was  such  that  in  case  of  a  fire  at  the 
mills  which  made  heavy  demands  for  water,  the  valves 
would  open  and  let  water  from  the  city  mains  into 
these  pipes;  when  the  pressure  in  these  pipes  was 
restored,  the  valves  would  close  again. 


176  TYPHOID    FEVER. 

On  July  1 8,  1903,  at  8  p.m.,  a  large  fire  broke  out  in  the 
mills  of  the  Merrimac  Manufacturing  Company,  and 
lasted  until  2  a.m.  the  next  day.  Mr.  George  Bowers, 
the  city  engineer,  has  given  the  following  account  of 
what  happened  at  that  time: 

"The  recording  pressure  gauges  show  that  soon  after 
the  fire  began  the  check  valves  opened,  and  the  city 
water  flowed  into  the  corporation  pipes.  Immediately 
after  the  fire  the  corporation  began  pumping  to  refill 
their  reservoirs,  but  after  several  hours'  work  little  head- 
way had  been  made.  This  led  to  an  investigation, 
which  revealed  the  fact  that  one  of  the  check  valves 
remained  open  when  the  increased  pressure  was  applied, 
driving  the  polluted  Merrimac  River  water  into  the  city 
main,  and  mixing  it  with  driven-well  water  at  a  point  in 
the  center  of  the  city  where  there  is  a  large  consumption 
of  water.  In  a  few  days  a  large  number  of  people  were 
taken  violently  ill,  and  an  epidemic  of  cholera  morbus 
ensued.  In  about  three  weeks  a  great  many  cases  of 
typhoid  fever  were  reported,  followed  by  a  serious 
epidemic  of  the  same. 

"  At  every  connection  is  a  gate  controlled  by  the  city, 
and  these  gates  were  closed  soon  after  the  typhoid  fever 
broke  out,  and  have  remained  closed.  The  city  has 
placed  extra  hydrants  in  the  streets  near  the  corpora- 
tions for  their  benefit,  and  the  mills  themselves  are 
enlarging  their  own  water-supply.  In  the  spring  the 
city  will  remove  all  connection  between  the  two  systems." 

This  occurrence  illustrates  in  a  striking  manner  the 
damage  which  a  comparatively  small  amount  of  polluted 
water  may  do. 


TYPHOID   FEVER  EPIDEMICS.  177 

This  epidemic  may  be  fairly  termed  one  due  to  accident. 
Yet  it  is  an  accident  that  should  have  been  avoided. 
Such  connections  of  the  city  mains  with  fire  service  pipes 
supplied  with  impure  water,  as  those  at  Lowell,  are  a 
source  of  danger.  These  connections  are  more  common 
than  is  generally  supposed.  The  insurance  companies, 
in  arranging  their  rates,  favor  those  mills  which  are 
supplied  with  water  from  two  independent  sources, 
both  available  in  case  of  fire.  In  some  cities  many  of 
these  objectionable  connections  exist. 

Several  recent  instances  might  be  cited  where  small 
outbreaks  of  typhoid  fever  have  occurred  in  cities 
supplied  with  filtered  water,  and  the  filters  have  been 
unjustly  blamed  for  a  trouble  which  was  really  caused 
by  these  fire  connections.  In  one  case  a  very  severe 
epidemic  started  in  this  way.  It  is  well  known  by  engi- 
neers that  the  check  valves  used  in  these  cases  do  not 
always  operate  properly,  —  they  seldom  close  absolutely 
tight,  and  sometimes  they  become  stuck  when  wide  open. 
Very  seldom  are  they  cared  for  after  being  installed, 
and  often  the  pipes  are  covered  with  earth,  so  as  to  make 
the  valves  inaccessible  without  digging.  It  has  'been 
suggested  that  by  the  use  of  improved  check  valves, 
arranged  in  duplicate,  ample  protection  of  the  quality 
of  the  city's  supply  may  be  secured,  but  it  must  be 
admitted  that  it  is  far  safer  to  sever  all  connections  of 
pipes  carrying  polluted  water  from  the  city  mains.  In 
many  places  the  latter  course  is  being  drastically  carried 
out. 

The  Millinocket  Epidemic.  Another  instance  of  a 
typhoid   fever  epidemic  due  to  an  accidental  pollution 


178  TYPHOID    FEVER. 

of  the  public  water-supply  which  occurred  as  the  result 
of  a  fire,  was  that  of  Millinocket,  Maine,  in  1904. 

Millinocket  is  a  paper-mill  town  recently  established 
near  the  head  waters  of  the  Penobscot  River,  84  miles 
above  the  city  of  Bangor.  The  village  had  a  water- 
supply  satisfactory  in  quality,  but  deficient  in  pressure. 
In  case  of  fire  it  was  necessary  to  pump  water  into 
the  mains  from  the  Millinocket  River,  a  tributary  of  the 
Penobscot,  and  the  place  where  this  was  done  was  at 
the  paper  mill  below  the  town  and  below  the  outlet  of 
the  sewers. 

On  January  29,  1904,  a  fire  occurred  in  the  village, 
and  this  pump  at  the  mill  was  used.  As  a  result, 
there  was  an  epidemic  of  diarrhea,  or  "  winter  chol- 
era," during  which  more  than  200  people  were  made 
sick. 

On  February  21,  a  second  fire  occurred.  The  mill 
pump  was  used,  and  it  is  said  that  for  several  days  after 
the  fire  the  polluted  river  water  was  pumped  into  the 
street  mains,  the  gate  not  having  been  fully  closed. 
This  time  an  epidemic  of  typhoid  fever  resulted.  It 
began  on  March  2,  when  4  cases  occurred,  and  developed 
gradually  until  more  than  200  were  made  sick.  Between 
March  i  and  May  i,  16  persons  died  of  the  disease. 

This  epidemic  had  an  unfortunate  sequel.  The 
sewage  of  Millinocket  emptied  into  the  Millinocket 
River  and  passed  down  into  the  Penobscot.  Bangor, 
84  miles  below,  used  the  river  water  imperfectly  filtered, 
and  so  did  the  cities  of  Old  Town  and  Brewer.  In 
each  of  these  places  epidemics  of  typhoid  fever  occurred 
during  the  months  of  April  and  May.     In  all  there  were 


TYPHOID   FEVER  EPIDEMICS.  1 79 

more  than  600  cases:  in  Bangor  alone,  there  were  36 
deaths. 

The  far-reaching  effect  of  the  "accident"  at  Milli- 
nocket  is  seen  from  these  facts.  One  cannot  help 
wondering  if  the  time  will  not  come  when  some  one  will 
be  held  responsible  for  such  "accidents." 

The  Baraboo  Epidemic.  .\n  epidemic  occurred  in  the 
town  of  Baraboo,  "Wis.,  during  the  summer  of  1901, 
which  may  be  considered  as  due  to  accident.  It  began 
in  May  and  continued  until  October,  during  which  igo 
cases  and  15  deaths  occurred.  The  public  water-supply 
was  taken  from  ground  water,  but  the  suction  pipe  was 
laid  through  a  flume  which  carried  polluted  water.  At 
the  pumping  station  there  were  two  water-power  pumps, 
—  one  used  for  pumping  ground  water  to  the  city,  and  the 
other  used  for  pumping  river  water  from  the  flume  for 
railroad  uses.  There  was  also  a  steam  pump  used  as  a 
resers^e  at  times  of  low  water,  arranged  so  that  it  could 
pump  either  ground  water  or  flume  water.  The  season 
of  1 901  had  been  dry,  and  the  steam  pump  had  been  used 
more  than  usual.  Comparison  of  the  dates  when  the 
steam  pumps  were  used,  with  the  occurrence  of  the 
typhoid  fever  in  the  town,  showed  a  direct  correspondence 
between  them;  and  an  examination  of  the  intake  pipe 
showed  that  the  foot  valves  in  the  suction  pipe  of  the 
flume  leaked  so  that  when  the  steam  pump  was  used, 
water  from  the  flume  was  pumped  into  the  supplv.  On 
repairing  these  leaks  typhoid  fever  in  the  city  immediately 
subsided. 

An  Outbreak  on  One  of  the  Great  Lakes  Steamers. 
An  interesting  example  of  what  was  probably  an  acci- 


•y 


1 80  TYPHOID    FEVER. 

dental  contamination  of  water  occurred  on  one  of  the 
large-  passenger  steamboats  on  the  Great  Lakes  plying 
between  Buffalo  and  Duluth.  One  of  the  victims  has 
related  the  following  incident: 

"We  left  Buffalo  on  June  29,  1906,  and  passed  Detroit 
about  noon  of  the  31st.  During  the  night  following, 
about  30  or  40  passengers  were  taken  violently  ill  with 
severe  intestinal  disturbances;  and  two  or  three  weeks 
afterwards  a  number  of  these  came  down  with  typhoid 
fever,  I  being  among  the  number.  On  inquiry  I  learned 
from  one  of  the  officers  that  the  supply  of  drinking-water, 
usually  taken  from  the  middle  of  Lake  Erie  where  it  is 
pure  and  wholesome,  had  run  short,  and  that  the  tanks 
had  been  filled  in  the  Detroit  River  at  a  point  not  far 
below  Detroit,  that  is  in  the  path  of  the  city's  sewage." 

The  following  summer  there  was  another  outbreak 
among  the  passengers  and  crew  on  the  same  steamer, 
which  resulted  in  upwards  of  70  typhoid  cases  and 
at  least  5  deaths.  Among  those  who  contracted  the 
disease  were  5  musicians  and  12  chambermaids  em- 
ployed on  the  boat,  and  some  of  the  crew.  An  in- 
vestigation of  this  outbreak  was  made  by  the  Board 
of  Health  of  Buffalo,  which  showed  that  the  water  in 
some  of  the  tanks  was  contaminated,  while  the  toilet 
rooms  and  kitchens  of  the  boat  were  in  an  unsanitary 
condition.  This  led  to  an  extensive  cleansing  of  certain 
parts  of  the  steamer,  and  to  the  disinfection  of  the  water- 
supply  tanks  by  the  health  authorities;  and  after  some 
delay  the  vessel  was  allowed  to  clear  from  Buffalo, 
upon  the  agreement  of  the  company  to  supply  sterilized 
water  for  drinking   purposes,   and   to   duly  notify   the 


TYPHOID   FEVER  EPIDEMICS.  l8l 

passengers  and  crew  of  the  possible  dangers  of  the  tank 
water. 

This  is  probably  an  exaggerated  instance  of  some- 
thing that  occurs  more  or  less  frequently,  and  well 
illustrates  the  risks  that  one  is  compelled  to  run  in 
traveling. 

The  Lausen  Epidemic.  Historically  the  typhoid  epi- 
demic which  occurred  in  Lausen,  Switzerland,  is  of 
great  interest.  It  occurred  as  long  ago  as  1872, 
and  was  one  of  the  very  first  instances  where  the  dis- 
ease was  traced  to  the  public  drinking-water.  It  is 
interesting  also  from  the  remoteness  of  the  source  of 
infection. 

Sedgwick,  quoting  from  Dr.  Hagler's  report,  has 
given  the  following  account  of  the  epidemic : 

"The  epidemic  occurred  in  the  little  village  of 
Lausen,  which  had  a  population  of  780,  and  which 
up  to  that  time  had  never  suffered  from  typhoid  fever. 
Suddenly,  in  August,  an  outbreak  occurred  which 
affected  a  large  part  of  the  population.  Ten  cases 
were  reported  on  August  7,  and  they  continued  to  in- 
crease until,  at  the  end  of  the  epidemic  in  October,  130 
inhabitants  had  been  taken  sick,  besides  others  who  had 
spent  their  vacation  in  the  village.  The  fever  was 
distributed  quite  evenly  throughout  the  town,  with  the 
exception  of  certain  houses  which  derived  their  water 
^om  their  own  wells  and  not  from  the  public  supply. 

A  short  distance  south  of  Lausen  was  a  little  valley, 
the  Fiirlerthal,  separated  from  Lausen  by  a  hill,  the 
Stockhalden,  and  in  this  valley  on  June  19,  upon  an 
isolated  farm,  a  peasant  fell  ill  with  a  very  severe  case 


1 82  TYPHOID    FEVER. 

of  typhoid  fever,  and  within  the  next  month  there 
occurred  three  other  cases  in  the  neighborhood.  No 
one  in  Lausen  knew  anything  about  these  cases  until 
the  outbreak  occurred. 

The  water-supply  of  Lausen  was  taken  from  a  well, 
or  spring,  at  the  foot  of  the  Stockhalden  Hill  on  the 
Lausen  side.  The  well  was  walled  up,  covered,  and 
apparently  protected;  but  the  distribution  of  the  cases 
directed  suspicion  to  this  water  as  the  source  of  the 
trouble,  and  an  investigation  showed  that  this  suspicion 
was  well  founded.  There  had  long  been  a  belief  that 
the  Lausen  well  was  fed  by  a  large  subterranean  connec- 
tion with  the  brook  in  the  Fiirler  valley,  and  this  brook 
ran  near  a  peasant's  house  where  the  typhoid  fever 
cases  occurred,  and  was  known  to  have  been  freely 
polluted  by  the  excreta  of  these  patients.  The  belief 
that  an  underground  connection  existed  was  based  on 
observations  which  had  been  made  ten  years  before, 
when,  without  any  known  reason,  there  had  suddenly 
appeared  near  the  brook  in  the  Fiirler  valley  below  the 
hamlet  a  hole,  about  eight  feet  deep  and  three  feet  in 
diameter,  at  the  bottom  of  which  clear  water  was  flowing. 
As  an  experiment,  the  water  of  the  brook  was  turned 
into  this  hole,  with  the  result  that  it  all  disappeared  under- 
ground, while  an  hour  or  two  later  the  public  fountains 
at  Lausen,  which,  on  account  of  the  dry  weather  pre- 
vailing at  that  time,  were  barely  running,  had  begun^ 
flowing  abundantly.  They  continued  to  flow  until 
the  Furier  brook  was  returned  to  its  original  bed  and 
the  hole  had  been  filled  up;  but  every  year  afterward, 
whenever  the  meadows  below  the  site  of  the  hole  were 


TYPHOID  FEVER  EPIDEMICS.  183 

overflowed  by  the  waters  of  the  brook,  the  Lausen 
fountains  began  to  flow  more  freely.  In  1872,  just 
before  the  epidemic,  the  meadows  had  overflowed  just 
at  the  time  when  the  brook  had  been  infected  by  the 
excrements  of  the  typhoid  patients,  and  about  three 
weeks  after  this  overflow  the  disease  broke  out  in  Lausen. 

In  order  to  make  matters  more  certain,  however, 
experiments  were  made  by  putting  sah  into  the  hole 
referred  to,  whereupon,  soon  after,  the  water  in  Lausen 
gave  a  strong  reaction  for  chlorine.  In  another  experi- 
ment 5000  lbs.  of  flour  were  put  into  the  hole,  but  no 
starch  grains  appeared  in  the  Lausen  water,  and 
apparently  they  were  filtered  out  in  the  ground. 
Although  these  comparatively  large  particles  were  not 
found  in  the  Lausen  well  water,  there  is  every  reason 
to  believe  that  the  much  more  minute  germs  of  typhoid 
fever  found  their  way  underground  through  the  hill  to 
the  well  in  the  Lausen  valley." 

The  Basingstoke  Epidemic.  An  interesting  example 
of  a  typhoid  outbreak  due  to  the  infection  of  a  well  in 
a  limestone  region  is  that  of  Basingstoke,  England,  in 
September,  1905. 

Basingstoke  is  a  borough  of  about  10,000  inhabitants 
in  the  valley  of  the  river  Lodden,  a  tributary  of  the 
Thames,  and  is  built  wholly  on  the  chalk  foundation. 

The  water-supply  was  taken  from  two  wells,  10  feet 
in  diameter,  and  about  30  feet  deep.  From  one  of  them 
a  heading,  96  feet  wide  and  9.5  feet  high,  was  driven 
horizontally  into  the  chalk  over  a  hundred  feet,  branch- 
ing as  a  Y.  A  vertical  section  of  the  ground  at  the  well 
showed  three  horizontal  bands  of  flints  in  the  chalk, 


1 84  TYPHOID    FEVER. 

^nd  near  the  bottom  of  the  well  was  a  fissure,  through 
which  most  of  the  water  entered  the  wells.  The  two 
wells  were  connected  by  a  heading,  which  was  con- 
tinued on  the  other  side  of  the  second  well. 

At  various  times  a  sudden  turbidity  of  the  well  water 
after  rains  had  shown  that  subsoil  water  was  finding 
its  way  through  the  chalk,  and  this  subsoil  water, 
coming  from  the  low-lying  parts  of  the  town,  was  badly 
contaminated. 

The  epidemic  began  on  September  i8,  1905,  and  con- 
tinued through  October,  during  which  time  there  were 
164  cases  and  13  deaths.  The  explosive  character  of  this 
epidemic  was  notable.  It  began  about  three  weeks 
after  there  had  been  a  heavy  down-pour  of  rain  (August 
27),  —  an  interval  long  enough  to  allow  for  the  passage 
of.  surface  water  through  the  soil  to  the  well,  and  for  the 
incubation  of  the  disease. 

That  the  subsoil  was  polluted  in  the  vicinity  of  the 
well  was  made  evident  by  a  study  of  the  local  surround- 
ings by  Dr.  Farrar,  from  whose  report  these  data  are 
taken.  "Work  on  the  main  sewers  was  in  progress  in 
adjacent  streets,  and  the  trenches  became  filled  with 
water  contaminated  by  defective  sewer  connections. 
There  was  also  a  stoppage  of  a  sewer  and  an  overflow 
of  sewage  due  to  the  failure  to  remove  a  certain  plug 
after  making  some  repairs,  and  this  point  of  overflow  was 
not  over  150  feet  from  the  town  wells.  The  chances  for 
the  contamination  of  the  well  water  were  therefore  great." 

Although  contamination  of  the  water  at  this  time  was 
proven,  the  investigation  failed  to  disclose  the  particular 
case  of  typhoid  fever  which  infected  the  sewage. 


TYPHOID   FEVER  EPIDEMICS.  1 85 

As  soon  as  it  had  been  made  clear  that  the  outbreak 
was  due  to  the  well  water,  the  fissure  referred  to  was 
plugged  up,  and  the  reservoir  and  city  mains  were  dis- 
infected with  chloride  of  lime. 

The  Newport  Outbreak.  A  well  in  Newport,  R.  I., 
caused  a  typhoid  outbreak  in  September  and  October, 
1900,  which  was  carefully  studied  by  Professor  C.  E.  A. 
Winslow.  Of  the  80  or  more  persons  who  fell  ill  dur- 
ing these  two  months,  the  greater  part  lived  within  a 
radius  of  300  feet  of  the  well,  and  used  the  well  water. 
The  well  was  an  ordinary  shallow  well,  10  feet  deep  and 
8  feet  in  diameter,  with  sides  of  loose  stone  and  a  cover 
of  planking,  upon  which  those  who  used  the  water  stood 
while  operating  the  wooden  pump.  The  land  tributary 
to  this  well  included  some  twenty  privy  vaults  within 
400  feet,  the  nearest  being  only  25  feet  distant.  The 
water  level  in  the  well  was  only  2  feet  below  the  surface 
of  the  ground. 

It  appeared  that  on  August  31,  1900,  there  had  been  a 
case  of  typhoid  fever  in  a  house  which  had  a  privy  vault 
200  feet  from  the  well,  and  that,  on  September  3,  there 
was  another  case  in  a  house  300  feet  away.  It  was  found 
also  that  the  excreta  from  a  typhoid  patient  found  access 
to  the  privy  vault  which  was  only  25  feet  from  the  well. 
The  well  water,  therefore,  had  abundant  opportunity 
to  become  infected,  either  by  droppings  at  the  top  of  the 
well,  or,  as  Professor  Winslow  thought,  by  infected  water 
leaching  from  the  privies  through  the  ground. 

The  Auxerre  Epidemic.  Another  instance  of  sub- 
surface pollution  of  a  ground  water  which  produced  a 
typhoid  epidemic  was  that  of  Auxerre,  France,  which  has 


1 86  TYPHOID    FEVER. 

been  described  by  Count  Max  le  Couppey  de  la  Forest. 
In  May,  1902,  an  epidemic  broke  out  in  this  community, 
during  the  course  of  which  there  were  upwards  of  300 
cases.  The  water-supply  was  taken  from  a  collecting 
gallery  near  the  Yonne  River.  This  gallery  was  located 
in  permeable  gravel,  and  was  only  15  to  25  feet  distant 
from  a  canal  which  had  been  recently  dug,  and  which 
carried  the  water  of  a  neighboring  brook  parallel  to  the 
gallery  for  a  distance  of  about  250  feet.  It  seems  that 
this  brook  water  had  become  infected  from  a  case  of 
typhoid  fever  which  occurred  near  its  banks  in  April. 
The  brook  originally  flowed  in  an  old  ditch  alongside  of 
a  road,  and,  in  the  course  of  time,  this  ditch  had  become 
silted  up,  and  its  sides  presumably  rendered  thereby 
impermeable.  So  long  as  this  condition  remained,  no 
trouble  was  experienced,  even  though  cases  of  typhoid 
fever  had  occurred  on  the  brook  before.  It  was  not 
until  the  new  channel  was  dug  that  noticeable  contami- 
nation of  the  water  in  the  infiltration  gallery  took  place. 

Tests  were  made  by  putting  fluorescene,  or  uranine, 
into  the  water  of  the  stream,  and  after  a  few  hours  the 
characteristic  green  color  of  this  chemical  was  noticed  at 
the  pumps  of  the  waterworks.  It  must,  therefore,  have 
traversed  the  permeable  soil  for  a  distance  of  28  feet 
horizontally,  and  3I  feet  downwards,  at  the  rate  of  about 
12  feet  an  hour.  Quantitative  determinations  showed 
that  in  all  probability  the  water  of  the  brook  furnished 
one  thirteenth  of  the  supply  of  the  gallery. 

The  Trenton  Outbreak.  Sanitarians  believe,  and 
with  good  reason,  that  most  wells  that  become  infected 
receive  the  infectious  matter  at    the    top    rather   than 


TYPHOID   FEVER  EPIDEMICS.  18/ 

through  the  ground,  that  is,  by  the  direct  access  of 
fecal  matter  through  the  well  covering  or  by  the  inflow  of 
surface  water  at  times  of  rain.  Wells  in  limestone 
regions,  or  in  clay  beds,  where  crevices  abound,  or  wells 
in  coarse  gravel  soils  may  become  infected  by  the  passage 
of  typhoid  bacilli  through  the  soil,  but  in  sandy  soil, 
where  the  opportunities  for  natural  filtration  are  good, 
this  danger  is  far  less,  unless  privies,  cesspools  or 
sewers  are  quite  near  the  well. 

That  a  well  water  may  become  infected  by  the  passage 
of  typhoid  bacilli  through  the  soil  for  a  long  distance 
was  shown  by  some  interesting  investigations  made  by 
Professor  Earle  B.  Phelps  at  Trenton,  N.J.,  where  an 
epidemic  occurred,  in  June  and  July,  1907,  at  the  State 
Hospital  for  the  Insane. 

The  well,  or  spring,  which  gave  rise  to  the  outbreak 
was  20  feet  in  diameter  and  only  10  feet  deep,  and  was 
located  300  feet  from  the  highway,  with  the  well  curb 
18  feet  and  the  bottom  28  feet  below  street  grade.  This 
water  was  pumped  to  the  buildings,  but  it  furnished 
only  a-  part  of  the  supply,  the  remainder  being  taken 
from  driven  wells.  The  hospital  sewer,  an  8-inch  tile 
drain,  passed  down  the  highway  mentioned. 

A  few  cases  of  typhoid  fever  occurred  in  April,  1907, 
and  a  few  more  in  May.  During  June  a  number  of 
new  cases  appeared,  and  in  July  there  were  52  cases 
in  the  men's  wards,  10  in  the  women's  wards,  and  a 
number  of  others  outside  the  grounds.  Altogether 
there  were  about  90  cases. 

On  June  16  it  was  learned  that  the  highway  in  the 
sewer  was  choked  up  and  overflowing  at  one  of  the 


1 88  TYPHOID    FEVER. 

manholes,  and  this  led  to  the  discontinuance  of  the  use 
of  the  well  water.  Studies  were  thereupon  made  to 
ascertain  whether  or  not  this  stoppage  of  the  sewer 
had  any  connection  with  the  contamination  of  the 
well  water,  which  analysis  showed  to  be  very  serious. 
Various  tests  were  made  which  showed  beyond  question 
that  the  sewage  found  its  way  from  the  street  to  the 
well  through  the  ground.  A  plug  was  put  in  the  sewer 
so  as  to  back  up  the  sewage  in  the  highway  near  the 
well,  while  measurements  were  made  of  the  quantity 
of  water  entering  the  well.  The  results  showed  a 
decided  increase  of  inflow  under  these  conditions. 
Coloring  matters  of  various  kinds  were  put  into  the 
sewage,  and  later  they  appeared  in  the  well.  Proof 
of  contamination  could  scarcely  be  stronger.  Bacterio- 
logical examination  also  gave  confirmatory  results. 

The  hydraulic  studies  showed  that  the  flow  of  sewage 
to  the  spring  was  large  and  rapid,  —  so  much  so  that 
it  seemed  certain  that  the  flow  was  not  one  of  simple 
percolation  through  soil,  but  rather  a  flow  through 
fissures  and  cracks. 

This  instance  is  instructive,  as  it  reveals  the  uncer- 
tainties of  soil  purification  and  the  existence  of  unsus- 
pected crevices  and  cracks.  While  soil,  under  favorable 
conditions,  may  protect  a  well  from  pollution,  the  only 
safe  rule  is  to  avoid  pollution,  and  to  make  sure  that 
the  well  is  outside  the  circle  of  influence  of  cesspool, 
sewer  or  privy. 

The  Mount  Savage  Outbreak.  Wells  and  springs 
on  hillsides  are  especially  liable  to  infection,  particularly 
in  limestone  regions  or  where  the  soil    is  clayey.     An 


TYPHOID  FEVER  EPIDEMICS. 


189 


instance  of  this  side-hill  pollution  occurred  at  Mount 
Savage,  Md.,  in  1904.  This  was  a  small  mining  town  on 
the  Potomac  River  watershed.  Through  it  ran  a  small 
stream,  known  as  Jenning's  Run,  which  was  grossly 
contaminated  with  fecal  matter  and  also  heavily  polluted 
with  acid  wastes  from  the  mines.  In  July  and  August 
an  outbreak  of  typhoid  fever  occurred  during  which 
about  120  were  made  ill.  Most  of  the  cases  were 
among  the  employees  at  a  brickyard.  The  following 
were  the  facts  appertaining  to  the  cause  of  the  outbreak. 


Fig.  20. 

Diagram  Showing  the  Way  in  Whicli  the  Brickyard  Spring  Became 
Contaminated  at  Mount  Savage,  Md.     (After  Parker.) 


On  July  4,  1904,  a  woman  who  had  been  nursing  a 
typhoid  patient  in  another  town  and  who  had  just  re- 
turned to  Mount  Savage  came  down  with  the  disease. 
She  lived  in  a  cottage  about  300  feet  above  the  brick- 
yard, on  a  steep  incline  that  forms  the  north  bank  of  Jen- 
ning's Run.  The  drainage  of  this  cottage  was  conveyed 


1 90  TYPHOID    FEVER. 

through  an  iron  pipe  which  emerged  from  the  ground 
about  50  feet  down  the  hillside  and  just  above  a  ditch 
that  received  part  of  the  drainage.  This  ditch  went 
along  the  side  of  a  road  which  passed  over  a  bank  of 
fire-clay.  At  the  bottom  of  the  fire-clay  bank  was  a 
spring  which  furnished  an  abundant  supply  of  clear, 
cool  and  supposedly  safe  water,  and  which  was  used 
by  nearly  all  of  the  200  employees  of  the  brickyard. 
The  relative  positions  of  the  cottage  and  spring  are 
shown  in  Fig.  20,  taken  from  an  abstract  of  Dr.  M. 
L.  Price's  report  prepared  by  Horatio  N.  Parker. 

Heavy  rains  occurred  during  the  first  week  of  July, 
which  in  all  probability  washed  infectious  matter  down 
the  hillside  from  the  end  of  the  house  drain  to  the 
open  ditch,  and  then  through  the  ground  to  the  spring. 
On  July  II,  one  week  after  the  arrival  of  the  typhoid 
patient  at  the  cottage,  twenty  workmen  at  the  brickyard 
were  taken  ill,  and  new  cases  occurred  daily  for  a  week 
or  two.  Dr.  Murray,  the  company's  physician,  suspected 
the  spring  at  the  very  beginning,  and  posted  a  notice 
directing  its  disuse.  This  warning  was  not  heeded,  how- 
ever, so  that  on  July  25  the  doctor  destroyed  the  spring 
by  filling  it  with  ashes  and  fire-clay  to  a  depth  of  sev- 
eral feet.  This  checked  the  outbreak.  Various  sanitary 
measures  were  taken  to  prevent  the  spread  of  the  disease. 
Other  springs  and  wells  were  either  closed  or  rendered 
undrinkable  by  putting  in  alum  or  copper  sulphate, 
privies  were  cleaned,  and  a  vigorous  campaign  of  dis- 
infection undertaken,  which  seems  to  have  been  success- 
ful in  preventing  a  general  epidemic. 

It   is    believed   that  this  outbreak  at  Mount   Savage 


TYPHOID   FEVER  EPIDEMICS.  191 

caused  an  infection  of  the  Potomac  River  water  in  the 
city  of  Washington,  185  miles  down  stream,  where  there 
was  an  unusual  increase  in  the  number  of  deaths  from 
typhoid  fever  during  September.  If  this  were  true, —  and 
the  figures  seem  to  indicate  that  it  was  true, —  the  typhoid 
fever  bacilli  must  have  successfully  passed  down  the  acid 
waters  of  Jenning's  Run  and  Will's  Creek,  down  the 
Potomac  River  for  185  miles,  and  through  the  reservoirs 
into  the  service  pipes.  The  filter  plant  was  not  then  in 
use. 

Epidemics  Due  to  Contagion,   to  Flies,  Etc. 

The  Outbreak  at  the  New  Haven  County  Jail.     In  the 

autumn  of  1904  a  typhoid  outbreak  occurred  in  the 
New  Haven  County  Jail.  Out  of  256  prisoners  there 
confined,  20  were  attacked  between  October  6  and 
November  15.  A  study  of  the  situation  by  Professor  H. 
E.  Smith  and  Mr,  Edward  Mahl  resulted  in  the  exoner- 
ation of  the  water-supply  and  the  milk-supply.  They 
found  that  on  the  street  adjoining  the  jail  there  were 
five  dwellings  in  which  cases  of  typhoid  had  occurred 
between  August  22  and  September  17.  The  privies 
in  the  rear  of  these  houses  were  in  a  very  filthy  condition, 
and  in  several  instances  fecal  matter  was  found  lying 
exposed  on  the  surface  of  the  ground.  The  food  fur- 
nished to  the  prisoners  was  prepared  at  the  jail,  and  often 
exposed  on  tables  in  front  of  open  windows  which  were 
not  screened.  Flies  were  abundant  at  the  time,  and  it  is 
a  well-known  fact  that  at  that  season  of  the  year  they 
seek  the  warmth  of  houses.  The  investigators  concluded 
that  the  outbreak  was  due  to  the  transfer  of  infectious 


192 


TYPHOID    FEVER. 


matter  by  flies  from  the  privies  to  the  food  furnished  the 
prisoners. 

The    Winnipeg    Epidemic.     The    city    of    Winnipeg, 
Manitoba,  the  principal  city  of  middle  Canada,  has  been 


APPROXIWIATE  POPULATION 

OF 

THE  SEVERAL  WARDS 

JANUARY,    1905 

W^rd 

Ward 

1 

5,000           4              20,000 

2 

13,000            5               25,000 

3 

11,000            6                 6,000 

Fig.  21. 

Winnipeg,  Manitoba.     Location  of  Typhoid  Cases  during  August  and 
September,  1904. 

recently  growing  at  a  very  rapid  rate.     Its  population 
was  44,800  at  the  time  of  the  last  Canadian  census  in 


TYPHOID  FEVER  EPIDE^IICS. 


193 


1901;  in  1907  it  was  estimated  as  110,000.  The  result 
of  this  growth,  while  of  great  commercial  benefit,  has 
been  to  make  more  difficult  the  problems  of  sanitation. 
Neither  the  waterworks  system  nor  the  sewer  system  has 
been  able  to  keep  pace  with  the  population,  and  the  result 
has  been  that  in  some  sections  of  the  city  there  are  many 
houses  which  have  no  sewer  connections,  but  depend  upon 
privies,  which  in  this  cold  climate  it  is  difficult  to  main- 
tain in  good  condition. 

For  a  number  of  years  typhoid  fever  had  been  preva- 
lent in  the  city,  but  in  1904  it  suddenly  increased,  — 
so  much  so  that  Dr.  E.  O.  Jordan  was  sent  for  to 
investigate  the  cause  of  the  outbreak.  The  data  given 
are  quoted  from  his  report.  The  new  cases  developed 
as  follows: 


Week  Ending  — 


July  10     . 

17     • 
24     . 

31     • 
August    8 


28 


September    4 


25 


October     2 

9 
16 


Number 
of  New 
Cases. 


10 
6 
6 

4 


23 
44 
41 

41 
47 
60 

65 

41 
51 
51 


Week  Ending 


1904. 
October  23 

31      • 

November    6 

13 
20 
27 

December     4 


1905. 
January    i 

9      • 
15      • 


Number 
of  New 

Cases. 


32 

55 

55 
41 
29 
25 

39 
27 

25 


27 
43 
77 


194 


TYPHOID    FEVER. 


These  figures  really  include  three  separate  outbreaks. 
The  first,  starting  in  August,  1904,  increased  slowly  until 
the  latter  part  of  September,  and  then  fell  off  somewhat 


APPROXIMATE  POPULATION 
OF  THE  SEVERAL  WARDS 
JANUARY, 1905 
Ward  Ward 

1 5,000    4 80,000 

2 13,000    5 25,000 

— ,11,000    6 6,000 


Fig.  22. 


Winnipeg,  Manitoba.     Location  of  Typhoid  Cases  during  October, 
November  and  December,  1904. 

rapidly  as  cool  weather  came  on.  The  cases  during  this 
period  were  confined  almost  exclusively  to  the  poorer 
sections  of  the  city,  and  were  evidently  due  to  direct 
contact  and  to  fly  transmission. 


TYPHOID  FEVER  EPIDEMICS.  195 

The  second  outbreak  began  in  October,  1904,  and  was 
a  short  and  sharp  attack.  The  third  began  in  January, 
1905,  and  was  even  more  severe.  These  later  outbreaks 
in  both  cases  followed  immediately  after  the  temporary 
pumping  of  water  from  an  abandoned  source,  the  Assini- 
boine  River,  to  supply  a  lack  of  water  for  fire  purposes. 
This  water  was  contaminated,  although  the  regular 
supply  of  the  city  was  of  excellent  quality,  being  taken 
from  driven  wells.  The  dates  of  pumping  the  Assini- 
boine  water  were  October  10  and  December  26.  Most 
of  the  cases  were  located,  not  in  the  poorer  sections,  as 
before,  but  in  a  fine  residential  district,  contiguous  to  the 
location  of  the  old  Assiniboine  Pumping  Station.  It  is 
supposed  also,  that  during  the  latter  part  of  1904  there 
was  a  slight  outbreak  due  to  infected  milk. 

Epidemics  in  Military  Camps.  Typhoid  fever  has  been 
the  great  scourge  of  our  army  camps,  and  it  has  always 
been  easier  for  our  soldiers  to  withstand  bullet  and 
bayonet  than  to  guard  against  the  ravages  of  the  insidious 
bacillus.  That  this  was  so  in  early  days  was  due  to 
ignorance;  that  it  has  been  so  in  recent  days  has  been 
due  to  gross  carelessness;  if  it  continues  to  be  so  in  the 
future,  "criminal"  may  not  be  too  strong  a  word. 

It  is  said  that  during  our  Civil  War,  in  the  two  years 
1862-63,  over  7000  deaths  from  typhoid  fever  occurred 
among  the  460,000  troops  in  the  Atlantic  Region.  In 
the  British  South  African  war  there  were  8000  typhoid 
deaths  among  230,000  men.  At  Bloomfontein  during 
the  months  of  March,  April  and  May  there  were  4667 
cases  and  891  deaths  among  40,000  troops.  During  the 
Spanish  War  of  1898,  among  107,973  troops  quartered 


196  TYPHOID    FEVER. 

in  our  army  camps,  there  occurred  20,738  supposed  cases 
of  typhoid  fever,  and  1580  deaths,  —  these  typhoid 
victims  constituting  86  per  cent  of  all  those  who  died 
from  disease.  This  typhoid  death-rate  is  appalling. 
It  amounted  to  1463  per  100,000,  and  the  records  did  not 
cover  a  whole  year,  but  only  the  summer  months.  If 
this  figure  is  compared  with  the  average  annual  death- 
rate  for  the  cities  of  the  United  States,  i.e.  35  per  100,000, 
the  enormity  of  the  epidemic  may  be  appreciated. 

The  commission  appointed  to  investigate  the  cause  of 
the  epidemics  in  the  various  camps  concluded  that  the 
transmission  of  the  disease  was  due  not  to  water  or  to 
food,  but  rather  to  direct  transmission  by  personal  con- 
tact, to  the  agency  of  flies,  and  perhaps  to  the  spread  of 
dried  fecal  matter  through  the  air  as  dust.  The  fifty- 
seven  general  statements  and  conclusions  of  their 
report  as  given  in  the  appendix  are  worthy  of  careful 
study. 

That  typhoid  .fever  need  not  decimate  our  fighting 
forces  has  been  demonstrated  by  our  own  navy  during 
the  Spanish  War,  by  our  army  in  the  Philippines,  and  by 
the  Japanese  army  during  its  war  with  Russia.  It  is 
also  shown  by  the  very  favorable  typhoid  statistics  for 
the  Panama  Canal  Zone. 

In  the  Spanish  War,  in  the  North  Atlantic  squadron, 
out  of  26,100  men  there  was  not  a  single  death  from 
typhoid  fever,  and  only  12  cases  during  the  entire  period 
of  service  amounting  to  114  days. 

Panama.  During  the  year  1906  there  were  62  deaths 
from  typhoid  fever  in  Panama,  Colon  and  the  Canal 
Zone.     The  average   population  during  this  year  was 


TYPHOID  FEVER  EPIDEMICS.  1 97 

about  66,000,  hence  the  death-rate  was  94  per  100,000. 
During  1907  the  population  has  increased  to  over 
100,000,  but  the  death-rate  has  been  substantially  the 
same.  This  rate  is,  of  course,  not  low,  but  when  all  the 
unfavorable  conditions  are  taken  into  account  it  is  re- 
markable that  there  has  been  no  serious  epidemic  from 
typhoid  fever  among  the  thousands  of  laborers  there 
employed.  The  work  of  Col.  W.  C.  Gorgas,  the  Chief 
Sanitary  Officer  of  the  Isthmian  Commission,  and  his 
associates  cannot  be  too  highly  commended. 

Japanese  Russian  War.  In  the  Japanese  army  it  is 
said  that  there  was  very  little  typhoid  fever  during  the 
war  with  Russia.  Major  Charles  Lynch  of  the  General 
Staff  United  States  Army  has  kindly  furnished  the 
following  figures,  which,  though  incomplete,  serve  to 
give  a  general  idea  of  the  situation: 

Strength  of  the  Japanese  army       1,220,000 

Number  killed  in  battle  or  died  of  wounds      .    .    .  58,887 

Number  died  of  disease  (14  months) 27,158 

Cases  of  typhoid  treated  at  the  Hiroshira  hospital 

from  July  12,  1904,  to  September  15,  1905    .    .    .  i)567 

Death  from  typhoid  in  the  same 299 

Cases  of  typhoid  treated  in  the  field  in  the  second 

army,  January,  1904,  to  April,  1905 104 

Cases  treated  in  the  Tokio  hospital,  in  1904     ...  89 

These  data  show  that  typhoid  fever  was  less  abundant 
in  the  Japanese  army  during  the  war  than  in  many 
American  cities.  Major  Lynch,  who  was  with  the 
Japanese  army,  says  that  the  disease  was  very  rare.  The 
troops  did  suffer  severely,  however,  from  other  diseases, 
and  in  particular  from  beri-beri. 

What  was  it  that  made  Japan  succeed  in  keeping 
typhoid  fever  away  from  her  armies,  while  the  United 


198  TYPHOID    FEVER. 

States  failed  so  ignominiously  ?  Major  Louis  Seaman 
says  that  it  was  because  of  the  care  to  secure  pure 
drinking  water  and  to  properly  dispose  of  fecal  matter, 
and  because  of  the  campaign  waged  against  flies.  In 
his  "Real  Triumph  of  Japan,"  he  tells  of  the  attention 
paid  to  the  burial  of  all  stable  manure,  to  the  destruc- 
tion of  garbage  and  the  general  elimination  of  breeding 
places  of  flies;  and  he  graphically  depicts  the  little  Japa- 
nese soldiers  turning  themselves  into  an  army  of  fly- 
catchers, with  ingenious  devices  for  catching  them. 
Apparently  the  soldiers  had  been  taught  to  realize  that 
the  catching  of  flies  was  as  much  an  act  of  patriotism 
as  the  shooting  of  a  Russian.  Whether  or  not  this  be 
exaggeration,  and  whether  or  not  the  Japanese  privates 
understood  what  sanitary  science  meant,  one  thing 
seems  certain,  namely,  that  the  Japanese  officers  under- 
stood the  value  of  taking  proper  sanitary  precautions, 
were  quick  to  discover  how  to  put  principles  into  prac- 
tice, and  were  firm  in  enforcing  obedience  to  the  orders 
of  the  medical  officers. 

Another  important  reason  for  the  absence  of  typhoid 
fever  was  that  the  army  was  almost  constantly  on  the 
move.  They  did  not  stay  long  enough  in  one  place  for 
camp  infection  to  do  its  fatal  work.  It  has  been  uni- 
versal experience  that  a  moving  army  is  healthier  than 
an  army  at  rest. 

Epidemics  Due  to  Injected  Milk. 

The  Somerville  Outbreak.  Between  August  20  and 
September  10,  1892,  an  outbreak  of  typhoid  fever 
occurred   in   Somerville,   Mass.,  which  was  studied  by 


TYPHOID   FEVER  EPIDEMICS.  1 99 

Professor  Sedgwick.  Among  the  32  cases  which  occurred, 
30  took  milk  from  the  same  milkman.  Investigation 
showed  that  the  farms  from  which  the  milk  was  derived 
were  in  excellent  condition,  and  that  no  typhoid  fever 
existed  upon  them.  The  milk  was  brought  to  the 
city  in  large  shipping  cans  and  carried  to  a  milk-house, 
where  the  supply  of  one  day  was  mixed  in  large  metal 
tanks  with  faucets  at  the  bottom.  After  mixture,  the 
milk  was  drawn  off  in  small  cans  for  distribution  to  the 
consumers. 

The  milkman  had  two  sons,  one  of  whom  had  typhoid 
fever  during  and  just  before  the  outbreak.  This  son 
drove  one  of  the  milk  carts,  and  it  was  his  duty  to  wash 
the  cans.  In  all  probability  he  did  other  work  also 
around  the  milk-house,  although  his  brother,  who  did 
not  take  the  disease,  was  said  to  look  after  the  mixing. 
A  few  of  this  milkman's  customers  were  supplied  with 
milk  direct  from  the  farms,  which  had  not  been  sent  to 
the  milk-house,  and  no  typhoid  fever  developed  among 
these.  The  evidence  went  to  show  that  the  infection 
occurred  in  some  way  at  the  milk-house. 

The  Springfield  Outbreak  of  1892.  In  July  and 
August,  1892,  an  outbreak  of  typhoid  fever  occurred  at 
Springfield,  Mass.,  which  resulted  in  150  cases  and  25 
deaths.  This  epidemic  was  studied  by  Professor  Wm.  T. 
Sedgwick  and  Dr.  W.  H.  Chapin.  Nearly  all  of  the 
cases  occurred  among  the  takers  of  milk  from  a  single 
milkman.  Part  of  his  milk  was  obtained  from  a  farm 
in  Agawam.  It  seems  that  in  the  spring  of  that  year  the 
farmer's  daughter  had  had  an  attack  of  "bilious  fever," 
while  there  had  been  other  cases  of  "slow  fever"  on  the 


200  TYPHOID    FEVER. 

place,  and,  in  all  probability,  all  of  these  cases  were 
really  typhoid  fever. 

It  was  learned  that  the  farmer  was  in  the  habit  of 
cooling  his  milk  by  lowering  the  cans  into  a  well  adjoin- 
ing the  cow-yard,  and  furthermore,  that  he  used  to  sub- 
merge his  cans  and  let  them  sink  to  the  bottom,  where 
they  would  be  covered  with  from  two  to  four  feet  of 
water.  There  the  morning  milk  stood  all  day  and  the 
night  milk  all  the  evening.  Out  of  the  nine  cans  ex- 
amined, four  were  found  to  leak  around  the  stopper,  and 
none  of  them  were  quite  full  when  they  were  put  into  the 
well.  As  a  natural  consequence,  the  cans  filled  with 
water  when  submerged. 

The  well  was  an  ordinary  shallow  dug  well,  covered 
with  loose  planks.  The  cans  were  lowered  into  the  well 
by  means  of  a  rope,  which  passed  through  a  hole  in  one 
of  the  planks  and  was  secured  with  a  knot.  There  was 
also  a  pump  in  the  well.  Opportunities  for  the  pollu- 
tion of  the  well  water  by  substances  falling  between 
the  planks  were  good,  and,  in  fact,  at  the  time  when  the 
place  was  examined,  clumps  of  manure  were  found  on 
the  planks.  The  infection  of  the  well  water  was  thought 
to  have  occurred  in  the  following  way. 

"The  excreta  of  the  patients  went  into  the  privy  with- 
out disinfection,  and  the  contents  of  the  privy,  shortly 
before  the  outbreak  in  Springfield,  had  been  spread  upon 
a  tobacco  field  through  which  the  workmen  frequently 
passed  to  the  well  to  get  water  or  to  work  about  the  milk. 
It  is  not  difficult  to  believe  that  in  doing  so  they  may 
have  carried  upon  their  boots  masses  of  fecal  matter 
from  the  privy,  through  the  field  to  the  well,  and  that 


TYPHOID   FE\'ER   EPIDEMICS. 


20I 


pieces  of  it  fell  through  the  cracks  into  the  water  while 
the  men  trod  upon  the  irregular  planking." 

The  Stamford  Outbreak.  A  severe  outbreak  of  typhoid 
fever  caused  by  infected  milk  occurred  in  Stamford, 
Conn.,  in  1895.  Between  xA.pril  15  and  May  28  there 
were  386  cases  and  22  deaths,  distributed  as  follows: 


Period. 

Number   • 
of  Cases.  \ 

Period.                     '  ^mnber 
of  Cases. 

April  15-22 

23-29      

30-May  6     .    .    . 

176 

97 
80 

May    7-13      

14-28      

18 
15 

These  figures  w^ell  illustrate  the  sudden  onset  of  the 
disease  characteristic  of  a  typical  milk  epidemic. 

The  distribution  of  the  cases  according  to  ages  is  also 
interesting,  as  it  shows  an  unusually  large  proportion 
among  children,  who  naturally  drink  more  milk  than 
older  people,  and  are  therefore  more  exposed  to  infection. 


Age. 


Number  of 
Cases. 


Percentage 
Fatality. 


o-io    .     .     . 
10-20   .    .    . 

20-30  .  .  . 
30-40  .  .  . 

40-50  .   .   . 

Total 


134 
92 


44 
19 


1-5 
I.I 

"•5 
15-9 
10.5 


386 


Of  these  386  cases,  368,  or  95  per  cent,  occurred 
among  those  who  took  milk  from  a  certain  dealer,  or  who 
had  access  to  milk  purchased  from  him.  This  dealer 
procured   his   milk   from   three   producers,    but   it   was 


202  TYPHOID    FEVER. 

demonstrated  that  the  infection  probably  came  from 
the  premises  of  the  milkman  himself,  and  that  it  was 
caused  by  using  infected  water  from  a  contaminated 
well  to  wash  the  cans.  The  original  cause  of  the  infec- 
tion, however,  was  not  discovered. 

The  Marlborough  Outbreak.  An  interesting  instance 
of  the  spread  of  typhoid  fever  from  a  creamery  occurred 
in  Marlborough,  Mass.,  in  August,  1894.  There  were 
150  cases,  47  of  which  occurred  on  the  route  of  a  milk- 
man who  sold  only  skimmed  milk.  This  milk  was 
obtained  from  a  creamery  which  received  its  supply  from 
a  large  number  of  dealers.  It  was  found  that  the 
driver  of  the  milk-wagon  had  been  ill  with  typhoid  fever, 
and  although  he  took  to  his  bed  after  the  outbreak  had 
begun,  it  was  thought  that  he  had  been  ill  with  the 
disease  for  a  number  of  weeks  before  that.  Besides 
driving  the  milk-wagon,  this  man  also  had  the  handling 
of  the  milk  in  the  creamery,  and,  as  a  number  of  opera- 
tions were  involved,  the  chance  for  infection  was  great. 

The  Waterbury  Outbreak.  In  June,  1890,  an  out- 
break of  typhoid  fever  occurred  in  Waterbury,  Conn., 
during  which  there  were  upwards  of  50  cases,  and  about 
12  deaths.  Professor  Herbert  E.  Smith  investigated  this 
outbreak  and  found  that  of  the  50  cases,  41  took  milk  from 
the  same  milkman.  In  one  case  milk  was  purchased 
from  a  dealer  who  bought  milk  from  this  milkman,  and 
in  another  case  the  patient  had  eaten  ice  cream  made 
from  milk  obtained  from  the  same  source.  This  out- 
break was  traced  to  one  of  the  farms  which  supplied 
milk  to  the  dealer  in  question.  On  this  farm,  prior  to 
the  outbreak,   there  had  been  three  cases  of  typhoid 


TYPHOID   FEVER  EPIDEMICS. 


203 


fever,  —  the  farmer,  his  daughter,  and  the  farm-hand. 
Just  how  the  infection  was  conveyed  to  the  milk  was  not 
definitely  learned,  as  there  were  a  number  of  ways  in 
which  it  might  have  occurred.  In  the  first  place,  the 
farm-hand  milked  the  cows  during  the  early  part  of 
June  while  ill  with  the  disease.  He  was  uncleanly  in  his 
habits,  and  some  of  his  fecal  matter  is  known  to  have 
been  thrown  upon  a  manure  pile  adjoining  the  barn. 
Most  suspicion  seems  to  have  been  attached  to  the  water 
used  on  the  premises  for  drinking  and  for  washing  the  cans. 
The  distribution  of  the  cases  during  the  month  was  as 
follows : 


Period. 

Number 
of  Cases. 

Period. 

Number 
of  Cases. 

June    8-10   

11-15   

16-20   

3 

15 

9 

June  21-25 

26-30    

10 
6 

The  farm-hand  referred  to  took  to  his  bed  on  June  7, 
and  was  taken  to  the  hospital  on  the  9th,  but  for  more 
than  a  week  previous  to  this,  although  ill,  he  had  kept 
at  work  and  taken  his  usual  part  in  the  milking,  handling 
the  milk  and  caring  for  the  cows. 

In  this  outbreak,  the  age  distribution  was  as  follows: 


Age. 

Number 
of  Cases. 

Age. 

Number 
of  Cases. 

I-IO 

11-15      

16-20      

21-25      

9 
14 
13 
10 

26-30      

31-35      

Over  35 

5 
4 
5 

204  TYPHOID    FEVER. 

These  figures  show  a  preponderance  of  cases  among 
children. 

The  Montclair  Outbreak.  In  1902  a  small  outbreak 
of  typhoid  fever  occurred  in  the  town  of  Montclair, 
N.J.,  and  in  Bloomfield,  N.J.  Although  this  outbreak 
included  only  about  28  cases  and  no  deaths,  its  cause  is 
of  much  interest. 

Seeking  to  find  the  explanation  the  health  officers  were 
baffled  by  the  fact  that  no  cases  of  sickness  could  be 
found  on  any  of  the  farms  supplying  milk.  At  length 
it  was  learned  that  all  the  cases  were  among  those  cus- 
tomers who  took  pint  bottles;  there  were  no  cases  among 
those  who  took  quart  bottles.  And  it  finally  developed 
that  there  had  been  a  case  of  typhoid  fever,  unreported 
to  the  health  department,  in  a  family  that  had  been 
served  daily  with  three  pint  bottles  of  milk.  These 
bottles  were,  of  course,  exchanged  each  day,  and  it  was 
found  that  they  were  not  sterilized  before  being  used 
for  other  customers,  but  merely  rinsed  and  filled  again 
with  milk.  There  seems  to  be  no  question  but  that  the 
disease  was  conveyed  by  means  of  these  imperfectly 
cleaned  and  unsterilized  bottles. 

Outbreaks  Due  to  Injected  Oysters. 

The  Wesleyan  Outbreak.  The  outbreak  of  typhoid 
fever  which  occurred  in  the  Wesleyan  University  in 
Middletown,  in  October,  1894,  is  of  especial  interest, 
as  it  was  one  of  the  earliest  epidemics  in  this  country 
to  be  attributed  to  infected  oysters.  The  outbreak 
began  rather  suddenly  on  October  20,  and  continued 
until  November  9.     During  this    time    there    were    25 


TYPHOID  FEVER  EPIDEMICS.  205 

cases  of  typhoid  fever,  of  which  13  were  very  severe, 
and  4  deaths. 

The  outbreak  was  investigated  by  Dr.  H.  W.  Conn, 
who  found  that  the  disease  was  contracted  at  a  series 
of  fraternity  dinners,  on  October  12,  the  occasion  being 
the  initiation  of  new  members.  After  studying  the 
various  articles  of  food  which  were  served  at  those 
dinners,  the  only  article  used  in  common  was  the  oysters, 
which  were  served  raw  on  the  half  shell.  These  oysters, 
it  was  afterwards  learned,  came  from  Fairhaven,  Conn., 
having  been  taken  from  deeper  water  in  Long  Island 
Sound.  Before  serving  to  the  consumers,  they  had 
been  allowed  to  lie  for  two  or  three  days  in  the  Quin- 
nipiac  River  to  fatten.  They  were  placed  there  on 
October  11. 

About  the  same  time  two  cases  of  typhoid  fever 
occurred  in  a  house  which  had  a  private  sewer  that 
emptied  into  the  river  at  a  point  not  more  than  300 
feet  away  from  these  oyster  beds.  One  of  these  patients 
died  on  October  21.  The  evidence  was  conclusive  that 
the  excreta  from  these  typhoid  patients  passed  through 
the  sewer  into  the  river  and  infected  the  oysters,  which 
were  served  at  the  fraternity  dinners. 

In  addition  to  the  Wesleyan  students  who  cam.e 
down  with  the  disease,  a  few  cases  developed  among 
visiting  students  from  other  universities,  while  a  number 
of  those  who  attended  the  dinners  also  suffered  from 
milder  intestinal  troubles.  It  is  said  that  the  number 
of  persons  who  were  made  ill  comprised  25  per  cent  of 
those  who  attended  the  dinners. 

The  Winchester-Southampton'  Outbreaks.     In  Novem- 


206  TYPHOID    FEVER. 

ber,  1902,  a  double  outbreak  of  typhoid  fever  occurred 
in  the  cities  of  Winchester  and  Southampton,  England. 
In  each  place  the  occasion  was  that  of  the  mayoral 
banquet;  these  banquets  happened  to  take  place  on  the 
same  day,  namely,  November  10.  At  Winchester,  out  of 
134  guests,  62  were  made  ill,  and  10  of  these  developed 
well-marked  cases  of  typhoid  fever.  In  Southampton, 
out  of  132  guests,  55  were  made  ill,  and  11  developed 
typhoid  fever.  These  epidemics  were  investigated  by 
Dr.  H.  T.  Bulstrode,  who  found  that  the  two  epidemics 
had  a  common  cause,  and  that  this  common  cause  was 
the  oysters  furnished  at  the  dinners,  which  had  been 
obtained  from  the  town  of  Emsworth.  Of  the  62  per- 
sons made  ill  at  Winchester,  61  ate  oysters  at  the  ban- 
quet, and  of  the  55  persons  made  ill  at  Southampton, 
54  ate  oysters.  In  both  places  all  who  developed 
typhoid  ate  of  the  oysters. 

The  oysters  were  purchased  on  the  same  day  from 
the  same  dealer,  at  Emsworth,  and  were  taken  from 
oyster  ponds  located  near  the  main  outfall  sewer,  which 
ponds  were  flooded  at  high  water.  The  pollution  of  these 
ponds  was  inevitable  from  their  situation.  Typhoid 
fever  had  been  present  for  some  time  at  Emsworth,  and 
there  seemed  little  doubt  that  the  outbreaks  referred  to 
were  caused  in  the  manner  indicated. 

The  Lawrence  Outbreak.  In  the  fall  of  1904  an 
outbreak  of  typhoid  fever  occurred  at  Lawrence,  Long 
Island,  a  village  near  the  famous  summer  resort  of  Far 
Rockaway.  Between  June  and  December,  31  cases  were 
known  to  have  occurred,  but,  in  all  probability,  the 
total  number  was  larger  than  this.     There   were  three 


TYPHOID   FEVER  EPIDEMICS.  20/ 

deaths.  The  outbreak  was  investigated  by  Dr.  George  A. 
Soper,  who  found  that  it  was  caused  by  the  eating  of 
oysters  taken  from  Jamaica  Bay  near  the  outlet  of  cer- 
tain sewers,  where  the  opportunities  for  infection  were 
great.  It  was  found  that  of  the  31  cases,  17  had  either 
eaten  raw  oysters  or  handled  their  fresh  shells. 

Outbreaks  Due  to  Infected  Fruit  and  Vegetables. 

The  Springfield  Outbreak  of  1905.  During  the  sum- 
mer of  1905  an  interesting  typhoid  outbreak  occurred  in 
Springfield,  Mass.,  due  to  a  cause  which  up  to  that  time 
had  not  been  well  recognized,  namely,  infected  fruit 
and  vegetables. 

The  epidemic  began  about  the  middle  of  July.  16 
cases  occurred  between  the  15th  and  the  28th  in  the 
poorer  section  of  the  city,  where  there  was  a  large 
foreign  population,  —  Jews,  Russians,  Syrians,  etc.  It 
was  learned  that  most  of  those  who  contracted  the 
disease  at  this  time  took  vegetables  from  one  man, 
whose  wife  had  been  ill  for  some  time  with  a  "  slow 
fever."  After  this  first  crop  of  cases  there  was  a  slight 
intermission,  but  early  in  August  new  cases  began  to 
appear,  this  time  among  the  better  classes  of  the  city, 
and  these  continued  through  the  month  and  well  into 
September,  until  by  the  end  of  the  month  there  had 
been  nearly  150  cases.  Among  the  foreigners  who 
first  contracted  the  disease  there  were  a  number  of 
venders  who  sold  fruit,  vegetables  and  bakery  stuflf 
through  the  streets  from  hand-carts,  and  it  was  found 
that  these  venders  delivered  goods  to  many  of  those 
who  afterwards  took  the  disease.     A  good  many  of  the 


2o8  TYPHOID    FEVER. 

later  cases,  however,  were  apparently  due  to  personal 
contagion,  as  the  sanitary  conditions  among  the  foreigners 
referred  to  were  very  bad. 

Outbreaks  Due  to  Infected  Ice. 

The  Ogdensburg  Outbreak.  There  is  no  authentic 
case  on  record  where  a  large  typhoid  fever  epidemic  has 
been  caused  by  infected  ice.  There  have  been  a  few 
instances  where  a  small  number  of  cases  have  been 
thought  to  have  been  so  caused,  and  there  have  been  other 
cases  where  milder  intestinal  disorders  have  been  attrib- 
uted to  ice,  but  in  nearly  all  of  these  instances  the 
evidence  has  been  weak. 

One  of  the  most  important  cases  was  that  of  the 
St.  Lawrence  State  Hospital  at  Ogdensburg,  N.Y.,  in 
1902,  when  39  cases  of  typhoid  fever  occurred.  The  ice 
there  used  was  unquestionably  contaminated,  and  in  all 
probability  infected  with  fecal  matter  from  typhoid  fever 
patients.  Lumps  of  dirt  were  found  frozen  into  the  ice, 
and  it  is  alleged  that  typhoid  bacilli  also  were  found. 

Another  outbreak  often  cited  is  that  of  the  military 
fort  at  Rennes,  France,  in  1895,  where  eight  officers  who 
had  drunk  champagne  mixed  with  iced  water,  were  taken 
ill,  the  ice  having  been  taken  from  a  contaminated  source. 

Outbreaks  Due  to  Miscellaneous  Causes. 

Without  doubt  all  the  ways  by  which  typhoid  fever 
is  conveyed  from  one  person  to  another  have  not  been 
found  out.  Each  year  some  new  discovery  is  made. 
Cases  are  on  record  where  the  germs  have  been  conveyed 
by  various  foods.     Among  these  are  the  Williams  College 


TYPHOID   FEVER  EPIDEMICS.  209 

outbreak,  due  to  cream;  the  Port  Deposit,  ]\Id.,  outbreak, 
due  to  ice  cream  infected  from  the  hands  of  the  man  who 
made  it;  the  Lambeth  and  Hackney,  England,  outbreaks, 
due  to  water-cresses ;  the '  Jersey  City  case,  attributed  to 
infected  celery;  the  South-end,  London,  outbreak,  due  to 
cockles.  It  is  singular  that  no  outbreak  has  been  traced 
to  food  from  bakeries,  restaurants,  or  hotels,  or  to 
candy  or  soda  water.  There  seems  to  be  no  reason  why 
any  article  of  food  which  comes  in  contact  with  the  hands 
of  those  making  or  selling  it  may  not  be  a  vehicle  of 
infection. 

Special  Characteristics  of  Epidemics. 

The  various  epidemics  and  outbreaks  which  have  been 
described  are  alike  in  some  respects,  but  each  one  has 
some  distinctive  feature. 

Looking  at  the  various  epidemics  due  to  infected  water, 
it  will  be  noticed  that  in  those  cases  where  river  water  was 
subject  to  constant  pollution,  the  disease  increased  rather 
slowly  and  did  not  reach  its  maximum  for  a  number  of 
weeks,  after  which  it  slowly  subsided;  while  in  those 
cases  where  the  water  became  suddenly  infected,  the 
disease  broke  out  violently  at  the  start,  and  sometimes 
came  as  a  series  of  blows,  —  one  after  the  other.  Out- 
breaks due  to  milk,  oysters,  etc.,  also  occur  with  explosive 
violence.  In  epidemics  due  to  contagion,  however,  the 
onset  is  likely  to  be  more  gradual.  All  epidemics,  how- 
ever, decrease  slowly,  and  many  cases  continue  to  occur 
for  a  long  time  after  the  fuU  force  of  the  blow  has  spent 
itself.  This  is  because  of  the  secondary  cases  due  to 
direct  contact  with  the  primary  cases.     Water  epidemics 


2IO 


TYPHOID    FEVER. 


generally  cover  longer  periods  than  outbreaks  due  to 
milk,  oysters,  etc.  These  distinctions  should  not  be 
too  sharply  drawn,  but  an  understanding  of  the  general 
tendencies   will  sometimes  be  of  service  in  tracing  the 


200 


150 


ui   100 


50 


MILK  OqjBREAK 

sta'iviford,cc)nn. 


^<^^/>/ 


T 1 


150 


100 


50 


WAjTER  EPIDEMIC 
ITHACA,  N.Y. 


4  5  6 

WEEKS 


Fig.  23. 
Diagram  Showing  Two  Types  of  Epidemics. 

origin  of  an  outbreak.  The  following  curves  represent 
rather  exaggerated  cases  of  two  of  these  types  of 
epidemics. 

Attempts    have    been    made    to    establish    a    relation 
between  the  intensity  of  infection  and  the  severity  of  the 


TYPHOID   FEVER  EPIDEMICS.  211 

disease,  but  generally  without  much  success.  In  out- 
breaks due  to  milk  or  oysters,  one  would  naturally 
expect  the  infection  to  be  severe,  the  dose  of  bacilli  to 
be  larger,  and,  in  consequence,  the  disease  to  be  more 
violent,  or  the  period  of  incubation  shorter.  To  a 
certain  extent  this  is  true,  but  in  all  probability  the 
severity  of  the  fever  depends  more  upon  the  constitution 
of  the  persons  infected  than  the  intensity  of  the  infection. 
Yet  one  may  readily  conceive  how  typhoid  bacilli  might 
retain  a  greater  degree  of  vitality,  and  presumably  of 
virulence,  in  such  a  good  culture  medium  as  milk  than 
in  an  unfavorable  medium  like  water.  There  may  be 
also  different  "strains"  of  the  bacillus,  —  some  of  which 
are  more  virulent  than  others,  —  but  such  speculation  as 
this  carries  us  beyond  the  known  facts  of  science.  There 
is  some  reason  to  believe,  however,  that  the  incubation 
period  is  shorter  and  more  uniform  in  the  case  of  intense 
infections  due  to  milk  or  to  direct  contact  than  in  the 
case  of  the  water-borne  type  of  the  disease,  when  the 
attenuation  of  the  bacteria  is  often  greater. 

Warnings,  It  is  a  famihar  saying  that  "Coming 
events  cast  their  shadows  before."  This  is  very  true  of 
typhoid  fever  epidemics,  although  not  universally  true. 
It  has  happened  on  many  occasions  that  an  outbreak 
of  typhoid  fever  has  been  preceded  by  an  unusual 
prevalence  of  diarrheal  troubles,  —  winter  cholera,  etc. 
Examples  of  this  have  been  already  referred  to.  These 
milder  disturbances  have  a  shorter  period  of  incubation 
than  typhoid  fever,  hence  they  are  manifested  earlier. 
Thus,  within  a  day  or  two  after  the  mayoral  banquets  at 
Winchester  and  Southampton  many  of  the  guests  were 


212 


TYPHOID    FEVER. 


taken  ill  with  intestinal  troubles,  but  the  typhoid  fever 
did  not  develop  for  ten  days  or  so.  So  also  in  the 
case  of  the  steamer  "Northwest."  The  prevalence  of 
diarrheal  diseases  in  any  community,  especially  during 
the  winter,  should  be  regarded  therefore  as  a  warning  of 
an  impending  calamity. 

One  of  the  best  illustrations  of  the  sequence  of  typhoid 
fever,  with  its  comparatively  long  incubation  period,  and 
intestinal  diseases  which  make  a  more  sudden  attack, 
is  that  of  Hamburg,  Germany,  during  the  cholera  epi- 
demic of  1892-93.  The  following  figures  show  the 
morbidity  for  these  two  diseases. 


Week  Ending  — 


Cases  of 
Cholera. 


Cases  of 
Typhoid 
Fever. 


1892. 

August         20  .... 

27  .... 

September    3  .... 

10  .... 

17  .... 

24  .... 

October        8  .... 

IS  .... 

22  .... 

29  .... 

November    5  .... 

12  .... 

20  .... 

27  .... 


IIS 
3593 
6157 
3217 
2092 
1224 

lOI 

41 
14 

I 

3 
S 
4 
3 


42 
38 
69 

139 
15s 
132 
76 
52 
43 
34 
32 
21 

15 
14 


Infection  Widespread.  The  question  is  often  asked, 
"  Where  does  the  original  infection  come  from  ?  "  Some- 
times in  an  outbreak  this  can  be  traced;  more  often  it 
cannot.     But  a  few  moments'  thought  will  show  that 


TYPHOID   FEVER  EPIDEMICS.  213 

there  is  no  lack  of  supply  of  typhoid  fever  in  the  United 
States.  Suppose  the  average  death-rate  from  this  disease 
throughout  the  cities  of  the  country  to  be  35  per  100,000. 
That  means  at  least  350  cases  per  100,000  per  year,  — 
or,  say,  one  case  each  year  to  every  250  or  300  persons. 
In  many  rural  districts  the  disease  is  even  more  prevalent 
than  this.  Such  being  the  case,  there  are  sure  to  be  some 
cases  of  typhoid  fever  among  the  thousands  of  farmers 
who  send  milk  to  the  great  cities,  and  who  handle  the  other 
food  supplies.  The  sewage  of  all  large  cities  certainly 
contains  the  typhoid  bacillus  at  some  time  in  the  year. 
Then  there  are  the  "typhoid  carriers"  and  the  resistant 
typhoid  cells  that  are  long  lived  and  that  may  exist  for 
months  in  the  contents  of  a  privy  or  cesspool,  or  in  the 
mud  at  the  bottom  of  a  stream  behind  some  dam. 
When  all  these  facts  are  taken  into  consideration,  the 
wonder  is  not  that  there  is  so  much  typhoid  fever,  but 
that  there  is  so  little. 

Many  more  epidemics  might  be  referred  to,  and 
doubtless  better  examples  than  those  cited  might  have 
been  picked  out,  —  but  enough  have  been  given  to 
illustrate  the  main  sources  of  infection.  In  some  cities 
supplied  with  impure  water,  there  is  a  constant  suc- 
cession of  epidemics,  —  a  new  infection  occurring  before 
the  last  has  loosened  its  hold.  And  all  over  the  country 
miniature  outbreaks  are  occurring  by  the  hundred.  Few 
of  them  reach  a  place  where  they  attract  other  than  local 
attention;  no  serious  attempt  is  made  to  ascertain  their 
origin,  — and  so  they  would  go  on,  widening  their  circle  of 
influence,  were  it  not  for  the  checks  imposed  by  sanitary 
science. 


214  TYPHOID    FEVER. 

Epidemics  as  Life  Savers.  Strange  as  it  may  seem,  the 
great  epidemics  have  done  more  than  almost  anything 
else  to  reduce  the  typhoid  death-rate  of  the  country, 
for,  by  reason  of  their  severity,  they  have  imperatively 
demanded  that  their  cause  be  ascertained  and  prevented. 
They  have  stimulated  research,  enlightened  the  public  as 
to  the  principles  of  sanitary  science,  and  compelled  city 
officials  to  apply  these  principles  for  the  good  of  the 
people.  They  have  aroused  careless  cities  to  the  need 
of  a  pure  water-supply;  caused  laws  to  be  passed  pre- 
venting the  sale  of  oysters  fed  near  the  sewers;  and 
increased  the  vigilance  of  milk  inspection.  They  have 
awakened  physicians,  and  citizens  as  well,  to  the  sense 
of  their  public  responsibilities  in  a  way  that  the  constant 
presence  of  a  high  death-rate  will  never  do. 

These  epidemics  are  usually  set  forth  as  terrible 
scourges,  —  and  so  they  are,  locally  considered,  —  but 
they  influence  the  general  death-rate  of  the  country 
very  little.  Or,  mathematically  expressed,  a  very  high 
death-rate  applied  to  a  small  population  causes  fewer 
deaths  than  a  moderate  death-rate  applied  to  a  large 
population. 

Thus,  during  the  famous  epidemic  year  in  Ithaca,  N.Y., 
in  1903,  the  death-rate  rose  to  625  per  100,000,  which, 
applied  to  a  population  of  13,156,  meant  82  deaths. 
During  the  same  year  the  average  death-rate  for  the 
state  of  New  York  was  only  21.5  per  100,000,  but  this, 
applied  to  the  total  population  of  7,600,000,  meant 
1665  deaths.  The  epidemic  attracted  attention;  the 
moderate  death-rate  did  not.  So,  too,  in  the  Spanish 
War,  the  shameful  occurrence  of  typhoid  fever  in  our 


TYPHOID   FEVER  EPIDEMICS.  21 5 

military  camps  aroused  general  indignation,  while  in  the 
Southern  states  and  elsewhere  in  the  country,  the  rural 
death-rate,  far  more  reaching  in  its  effects  and  sweeping 
away  a  far  greater  army  of  victims,  goes  on  year  after 
year  almost  without  comment. 


CHAPTER  IX. 

THE   INVESTIGATION   AND    CONTROL    OF    TYPHOID 
FEVER   EPIDEMICS. 

The  study  and  control  of  typhoid  fever  outbreaks 
and  epidemics  is  naturally  a  function  of  the  health 
authority, —  the  local  board  of  health,  or  health  officer, 
if  there  is  one,  or  the  county  or  state  board  if  there  is 
no  competent  local  authority.  The  matter,  however, 
is  one  which  usually  demands  quick  action  and  the 
sound  judgment  which  comes  from  experience,  and 
hence  it  is  becoming  quite  common  for  experts  to  be 
called  in  to  assist  the  local  authorities  or  to  take  charge 
of  the  situation.  To  trace  an  epidemic  to  its  source  is 
not  so  much  a  study  for  the  doctor  as  for  the  statistician, 
the  detective,  the  bacteriologist,  the  chemist  and  the 
engineer.  The  specialist  has  to  be  all  of  these  at  once. 
The  local  physician  is  sometimes,  but  not  always, 
equipped  for  the  task.  The  expert  is  more  likely  to 
see  the  facts  in  their  true  perspective;  he  is  also  more 
likely  to  obtain  the  cooperative  assistance  of  all  parties 
interested;  and  he  is  less  likely  to  be  influenced  by  the 
confusion  of  ideas  which  often  occurs  when  a  community 
suddenly  finds  itself  face  to  face  with  a  scourge  of 
unknown  origin. 

In  taking  up  the  investigation  of  an  epidemic  with 

216 


CONTROL  OF  TYPHOID   FEVER   EPIDEMICS.   21/ 

a  view  to  its  control  there  are  four  principal  things 
that  have  to  be  done: 

First.  It  must  be  ascertained  whether  or  not  the 
disease  is  actually  present,  and  whether  it  is  present,  as 
a  general  epidemic  or  merely  as  a  local  outbreak. 

Second.  The  cause  must  be  discovered. 

Third.  The  cause  must  be  removed. 

Fourth.  The  spread  of  the  disease  must  be  prevented. 

Collection  of  the  Data.  The  local  board  of  health, 
from  its  physicians'  reports,  should  be  the  first  to  learn 
of  the  existence  of  a  typhoid  increase,  but  often  the 
first  note  of  warning  comes  from  rumor  or  from  the 
daily  press.  Of  course,  if  the  physicians  fail  to  report, 
the  board  of  health  has  no  facts;  but  if  the  returns  are 
made  and  are  merely  tabulated,  but  not  studied  from 
day  to  day,  then  the  health  ofiicers  have  failed  in  their 
duty.  In  the  orderly  working  of  a  health  department 
any  increase  in  the  reported  new  cases  of  typhoid  fever 
would  lead  to  an  immediate  study  of  each  case,  and  to 
a  special  inquiry  among  the  physicians  as  to  the  pres- 
ence of  other  suspected  cases.  By  so  doing  an  epidemic 
would  often  be  nipped  in  the  bud,  without  alarming 
the  community.  There  is  perhaps  no  place  where  the 
saying  so  well  applies  as  here,  that  "a  stitch  in  time 
saves  nine." 

It  happens  more  often,  perhaps,  that  the  extent  of 
a  typhoid  outbreak  is  unduly  magnified.  A  reporter, 
seeking  copy,  starts  a  typhoid  scare,  and  alarms  the 
people  and  injures  the  reputation  of  the  city. 

The  first  thing  of  importance,  therefore,  is  to  find  out 
who  have  the  disease,  where  they  live,  and  where  they 


2l8  TYPHOID  FEVER. 

were  taken  sick.  These  and  various  other  statistics  are 
needed  in  tracing  the  epidemic  to  its  source.  The 
necessary  data  are  seldom  reported  to  the  heakh  depart- 
ment with  sufficient  completeness,  and  nearly  always 
a  special  canvass  has  to  be  made.  The  names  and 
addresses  of  the  patients  having  been  obtained  from 
the  health  departments  and  from  the  physicians,  house- 
to-house  visits  are  necessary  for  the  sake  of  obtaining 
first-hand  information  as  to  the  onset  of  the  disease,  the 
history  of  the  person  as  to  the  use  of  water,  milk,  food, 
etc.,  and  for  the  sake  of  making  a  sanitary  inspection 
of  the  premises. 

If  the  epidemic  is  an  extensive  one  it  is  convenient 
to  record  the  various  data  on  printed  forms  drawn  up 
to  fit  the  special  case.  The  principal  data  required 
are  the  following,  but  other  items  will  naturally  suggest 
themselves  in  particular  cases. 

SCHEDULE    OF    DATA    NEEDED     IN    THE    STUDY    OF 
TYPHOID    FEVER   OUTBREAKS. 

Number  of  case  (for  reference) 

Name  of  patient  ? 

Residence  ? 

Physician's  name  and  address  ? 

Date  of  physician's  report  ? 

Character  of  house  (private  house,  boarding  house,  apartment,  hotel, 

etc.)  ? 

Age  ? Sex  ? 

Occupation  ? Place  of  business  ? 

Where  living  month  previous  to  illness  ? -  —  . 

Absence  from  home  previous  to  illness  ? 

If  so,  where  ? " 

Date  of  first  symptom  ? Date  of  taking  bed  ? 

Date  of  doctor's  first  call  ? 


CONTROL  OF  TYPHOID   FEVER   EPIDEMICS.   219 

Date  of  leaving  bed  on  recovery  ? Date  of  relapse  ? 

Date  of  death  ? 

Blood  examined? Date? Result? 

Spleen  enlarged  ? Rose  spots  ? 

Sanitary  condition  of  premises  ? 

Source  of  drinking  water,  —  at  home  ?. . .  at  business  ? Elsewhere  ?.  . 

Milk  supply  from? Milk  habitually  drunk? 

Raw  oysters  eaten  ? Source  ? 

Patient  has  separate  room  ? Nurse  ? 

Were  stools  disinfected  ? the  urine  ? 

Any  other  precaution  taken  ? 

Other  cases  in  house  ?     (Obtain  names  and  dates) 

Other  cases  among  business  associates  ? 

Schoolmates  ? Friends  ? 

Number  of  people  in  the  house 

Remarks:    


Information  given  by. 
Information  given  to. . 
Date  of  information. . 


(Signed). 


Study  of  the  Data.  As  fast  as  the  data  are  obtained 
they  should  be  tabulated  and  studied  from  various  points 
of  view. 

Were  the  cases  generally  distributed  over  the  city  or 
were  they  confined  to  one  locality  ?  A  convenient  method 
of  ascertaining  this  is  to  take  a  street  map  and  locate  the 
cases  with  black-headed  pins  stuck  in  at  the  place  of 
residence.  This  map,  with  its  pins,  can  afterwards  be 
photographed  for  record.  If  the  cases  are  localized,  does 
the  locality  suggest  anything  as  to  a  common  cause? 
Is  it  coincident  with  some  particular  water-supply,  as  it 
was  in  New  Haven,  or  with  some  milk  dealer's  territory, 


220  TYPHOID    FEVER. 

as  in  Somerville?  Is  it  located  in  a  section  where  there 
are  no  sewers,  as  in  Winnipeg?  Is  it  around  some 
public  well,  as  in  Newport?  Or  are  the  cases  merely 
concentrated  in  one  place  because  the  population  is 
densest  there?  Does  the  geographical  distribution  of 
the  cases  change  as  the  epidemic  progresses  ?  Where  were 
the  early  cases  with  respect  to  the  others  ? 

What  was  the  probable  date  of  infection?  Was  there 
a  sudden,  sharp  attack,  or  was  the  onset  gradual?  If 
the  latter  was  the  case,  what  were  the  limiting  dates  of 
infection?  The  date  of  infection  has  to  be  estimated 
by  counting  back  from  the  time  when  the  patient  was 
taken  sick.  All  things  considered,  the  safest  date  to  count 
from  is  that  of  taking  bed.  Often  this  cannot  be  learned, 
especially  if  the  investigation  is  made  sometime  after- 
wards. But  the  date  of  going  to  bed  is  seldom  far 
from  the  time  of  the  physician's  first  call,  and  this  can 
usually  be  obtained  from  the  doctor's  memoranda.  If 
the  epidemic  is  believed  to  be  due  to  milk,  or  oysters,  or 
some  other  cause  involving  an  intense  form  of  infection, 
the  probable  date  when  the  patient  received  the  bacilli 
into  his  system  may  be  obtained  by  counting  back  7  to 
10  days;  but  if  a  water  infection  is  suspected,  a  period  of 
ID  to  15  days  will  probably  give  a  better  estimate.  It 
must  be  remembered,  however,  that  occasionally  the 
period  of  incubation  may  be  considerably  longer  than 
this.  Sometimes  it  is  necessary  to  count  back  from  the 
appearance  of  some  particular  symptom,  and  in  that 
case  the  attending  physician's  advice  should  be  obtained 
as  to  whether  this  occurred  in  the  second  or  third  or 
fourth  week  of  the  disease.     Sometimes  one  has  to  figure 


CONTROL  OF  TYPHOID   FEVER  EPIDEMICS.   221 

back  from  the  date  of  death.     That  also  is  something 
about  which  the  attending  physician  should  be  consulted. 

Were  there  any  outbreaks  of  diarrhea  preceding  the 
typhoid  epidemic?  When  and  among  whom  did  they 
occur  ? 

Were  most  of  the  cases  among  young  people  and 
children?  If  so,  this  suggests  milk  as  a  cause.  Did 
they  all  or  most  of  them  use  the  same  water-supply,  or 
take  milk  from  the  same  dealer,  or  food  from  the  same 
source  ? 

Had  the  patients  been  together  anywhere,  at  business 
or  in  school,  or  at  some  banquet? 

In  short,  was  there  any  common  cause  where  eating 
or  drinking  or  association  might  give  opportunity  for 
infection  ? 

If  the  public  water-supply  is  suspected,  investigations 
should  be  carried  on  to  determine  whether  or  not  the 
source  is  a  satisfactory  one,  whether  it  was  contaminated 
with  fecal  matter,  and  whether,  finally,  it  was  infected 
from  some  particular  case.  This  is  such  a  broad  sub- 
ject that  it  cannot  be  fully  gone  into  here.  The  aid 
of  the  bacteriologist  and  chemist  usually  has  to  be 
invoked,  and  the  interpretation  of  his  analyses  is  an 
important  matter  and  one  where  his  judgment  is  of 
equal  weight  with  the  figures  themselves.  It  must  be 
remembered,  however,  that  as  a  practical  test,  the  bac- 
teriologist cannot  tell  whether  or  not  the  typhoid  bacillus 
is  or  is  not  present  in  a  sample  of  water.  He  may  find 
the  colon  bacillus,  the  intestinal  germ,  and  that  will 
indicate  fecal  pollution,  i.e.,  domestic  or  animal  con- 
tamination, but  it  will  not  prove  of  itself  that  the  water 


222  TYPHOID    FEVER. 

is  infected.  Analyses  are  nearly  always  very  valuable 
and  even  necessary,  but  too  much  must  not  be  expected 
of  them,  particularly  as  the  samples  of  water  are  often 
not  collected  until  many  days  after  the  date  of  infection. 
An  inspection  of  the  source,  with  particular  respect  to 
the  occurrence  of  typhoid  fever  near  it,  is  of  the  utmost 
importance. 

In  connection  with  a  study  of  the  water-supply  the 
meteorological  conditions  should  be  taken  into  account, 
—  the  temperature,  the  rainfall,  the  occurrence  of  melt- 
ing snows,  floods,  etc. 

If  the  milk-supply  is  suspected,  inspections  of  the 
various  farms  should  be  made,  their  sanitary  conditions 
noted,  their  well-waters,  —  and  especially  the  occurrence 
of  typhoid  fever, or  "grippe,"  or  "bilious  fever,"  or  "slow 
fever"  or  something  that  might  be  typhoid  in  masque- 
rade, in  the  farmer's  family  or  among  his  employees. 
The  transportation  of  the  milk  and  its  distribution  should 
be  studied  with  reference  to  cleanliness  and  to  the 
occurrence  of  the  disease  among  those  employed. 

In  connection  with  oysters  it  must  be  remembered 
that  they  may  be  infected  at  their  layings,  or  during  the 
process  of  floating,  or  during  their  handling.  By  far 
the  greatest  chance  of  infection,  however,  comes  from  the 
practice  of  floating  in  sewage-polluted  waters. 

In  most  cases  these  various  investigations  are  not 
made  serially,  as  described,  but  are  all  carried  on 
together,  and  as  rapidly  as  possible,  in  order  to  learn  the 
cause.  Sometimes  an  expert,  because  of  his  experience, 
is  able  to  size  up  the  situation  very  promptly ;  whereas,  if 
left  to  local  study,  it  may  take  a  long  and  careful  investi- 


CONTROL  OF  TYPHOID   FEVER  EPIDEMICS.  223 

gation.  In  any  study  of  a  typhoid  fever  outbreak  one 
should  not  be  led  into  a  blind  attempt  to  trace  the 
disease  to  some  well-recognized  cause;  for  it  must  be 
remembered  that  science  does  not  yet  know  all  the 
means  by  which  the  germs  of  the  disease  may  be  spread. 

The  student  should  familiarize  himself  with  the  best 
methods  of  procedure,  by  a  careful  study  of  the  detailed 
reports  of  several  typical  epidemics. 

The  Control  of  Epidemics.  The  control  of  a  typhoid 
fever  epidemic  is  a  subject  upon  which  little  need  be 
said,  after  what  has  gone  before.  Obviously  there  are 
two  lines  of  action  required  —  the  removal  of  the  original 
cause,  and  the  prevention  of  the  spread  of  the  disease. 
The  actual  character  of  the  work  to  be  done  naturally 
depends  upon  circumstances,  but  in  a  general  way  it 
consists  of  putting  into  practice  the  various  sanitary 
measures  that  unite  to  form  the  three  barriers  of  enclosure 
and  the  three  lines  of  defense  described  in  earlier  chap- 
ters, —  with  this  exception,  that  these  lines  have  to  be 
drawn  more  strictly  than  under  ordinary  conditions. 

If  the  cause  of  the  epidemic  has  been  ascertained 
beyond  reasonable  doubt,  the  course  to  be  pursued  is 
usually  clear.  If  the  cause  has  not  been  definitely 
ascertained,  it  may  be  necessary  to  take  into  account 
one  or  more  suspected  causes,  and  to  act  in  each  case 
as  though  it  were  the  real  one.  This  naturally  involves 
some  unnecessary  work,  but  usually  the  matter  is  so 
serious  a  one  that  it  is  not  wise  to  take  any  chances  or 
leave  any  stone  unturned. 

If  a  well  water  has  been  found  to  be  infected,  it  is 
a  comparatively  easy  matter  to  discontinue  its  use,  dis- 


224  TYPHOID    FEVER. 

infect  the  well  and  thoroughly  clean  it  out;  if  a  milk- 
supply  is  at  fault,  a  thorough  process  of  cleansing  and 
disinfection  will  prevent  further  trouble;  but  if  the 
public  water-supply  is  found  to  be  the  cause,  the  situ- 
ation is  a  far  more  serious  one,  and  one  which  calls 
for  the  exercise  of  greater  skill  and  experience.  Just 
what  to  do  is  often  a  difficult  matter  to  decide,  as  much 
depends  upon  whether  the  infection  is  a  transient  one 
or  one  that  is  likely  to  persist  for  some  time,  and  whether 
the  infected  source  is  the  only  water-supply  available. 
If  a  city  has  more  than  one  supply  it  may  be  possible 
to  discontinue  the  use  of  the  one  that  is  suspected  as 
being  the  cause  of  the  epidemic,  and  depend  for  a  time 
upon  the  other  sources.  But  more  often,  perhaps,  the 
conditions  are  such  that  this  cannot  be  done,  and  that 
the  supply,  even  though  infected,  cannot  be  shut  off 
without  leaving  the  city  without  fire  protection.  In  this 
case  the  only  thing  to  do  is  to  discontinue  its  use  for 
drinking,  as  far  as  this  can  be  done,  and  to  depend 
upon  boiling  the  water  in  those  houses  where  no  other 
supply  can  be  obtained.  In  some  cities  it  has  been 
found  possible  to  temporarily  furnish  the  citizens  with 
spring  water,  distributed  without  charge,  or  for  a  merely 
nominal  charge. 

In  some  cases  efforts  have  been  made  to  disinfect  the 
entire  public  supply  in  order  to  render  it  safe.  This, 
however,  is  very  difficult  of  accomplishment,  except  in 
very  small  supplies;  in  large  supplies  it  is  practically 
impossible.  Copper  sulphate  has  been  held  up  as  a 
safe  and  efficient  chemical  to  be  used  for  this  purpose, 
and  no  doubt  its  use  in  some  cases  would  be  beneficial, 


CONTROL  OF  TYPHOID   FEVER  EPIDEMICS.   225 

but  there  are  reasons  to  believe  that  it  is  not  an  adequate 
remedy.  Dilute  solutions  of  copper  salts  will  kill  a 
large  percentage  of  typhoid  bacilli,  but  stronger  solutions 
seem  to  be  required  to  kill  the  more  hardy  forms  which 
have  been  referred  to  as  the  "resistant  minority,"  so 
that  in  order  to  completely  render  water  sterile  it  would 
be  necessary  to  use  large  quantities  of  copper, —  quan- 
tities so  large,  in  fact,  as  to  be  objectionable.  In  large 
supplies,  furthermore,  there  is  difficulty  in  applying 
the  chemical  so  as  to  properly  distribute  it  through  the 
water.  AMiile  disinfection  of  the  supply  might  do 
some  good,  yet,  taking  everything  into  consideration, 
there  is  probably  no  better  temporar}^  expedient  that 
can  be  adopted  than  to  thoroughly  boil  the  water  before 
it  is  used,  at  the  same  time  taking  steps  to  decrease  its 
use  by  providing  for  a  house-to-house  delivery  of  pure 
water. 

Filtration  of  water,  while  an  adequate  remedy,  cannot 
often  be  undertaken  as  an  emergency  measure,  although 
under  some  conditions  this  might  be  done.  It  often 
happens,  however,  that  a  typhoid  epidemic  that  has  been 
caused  by  an  infected  water  makes  such  an  impression 
on  the  community  that  filtration,  or  the  adoption  of  a 
new  supply,  soon  follows. 

To  control  an  epidemic  and  keep  it  within  bounds 
demands  prompt  and  energetic  measures.  An  epidemic 
is  almost  sure  to  bring  to  light  any  weak  spots  in  the 
sanitary  conditions  of  a  city.  It  must  be  remembered 
that  there  is  a  difference  between  contamination  and 
infection.  A  contaminated  well  water  may  be  used  for 
years  without  causing  typhoid  fever,  but  during  an  epi- 


226  TYPHOID    FEVER. 

demic  it  may  become  infected  as  well  as  contaminated,  as 
in  the  case  of  the  Barnes  well  at  Ithaca.  Many  other 
forms  of  uncleanliness  which  ordinarily  cause  no  serious 
trouble  may,  at  a  time  of  an  epidemic,  be  the  means  of 
spreading  the  disease.  Hence,  the  presence  of  typhoid 
fever  in  epidemic  form  in  a  community  demands  not  only 
the  removal  of  the  orignal  cause,  but  a  wholesale  house 
cleaning,  and  the  institution  of  far-reaching  sanitary 
reforms. 

Besides  taking  measures  to  rid  the  city  of  all  that 
might  tend  to  spread  the  disease  through  secondary 
infection,  it  may  be  necessary  to  take  extraordinary 
measures  to  secure  adequate  services  for  the  sick.  It 
may  be  necessary  to  bring  in  extra  physicians  and 
nurses  from  outside,  to  establish  a  temporary  hospital 
for  those  who  cannot  be  well  treated  in  their  homes,  to 
supply  freely  large  quantities  of  simple  disinfectants,  and 
to  make  many  blood  tests  of  suspected  cases.  During 
a  general  epidemic  the  importance  of  isolation  becomes 
greatly  increased,  as  the  disease  is  likely  to  take  greatest 
root  among  the  poorer  classes  of  population  where  con- 
tagion cannot  be  easily  prevented.  Hence  the  question 
of  hospital  service  at  such  times  becomes  one  of  para- 
mount importance.  The  board  of  health  should  have 
the  power  to  remove  patients  to  the  hospital  if  they 
cannot  be  treated  in  their  homes  without  danger  to 
others. 

Through  it  all,  a  "safe  and  sane  policy"  should  be 
consistently  pursued.  A  community  afiflicted  with  a 
typhoid  fever  epidemic  is  sometimes  almost  panic- 
stricken.     Correspondents  may  fill  the  public  press  with 


CONTROL    OF    TYPHOID    FEVER    EPIDEMICS.      227 

their  theories,  and  many  foolish  things  may  be  said 
and  done.  What  is  needed  is  a  strong  central  authority 
that  for  a  time  can  exercise  almost  autocratic  power, 
and  a  government  and  a  public  opinion  that  will 
uphold  such  authority,  and  provide  all  necessary 
resources.  Fortunate,  indeed,  is  the  city  that  has  a 
health  officer  or  health  department  equipped  for  such 
an  emergency  and  a  government  that  will  rise  to  the 
occasion. 


CHAPTER  X. 

THE    INFLUENCE    OF    PUBLIC    WATER-SUPPLIES    ON 
THE  TYPHOID  FEVER  DEATH-RATES  OF  CITIES. 

The  manner  in  which  the  sanitary  quality  of  public 
water-supplies  influences  the  typhoid  fever  death-rates 
of  cities,  has  been  sufficiently  discussed.  It  remains 
to  study  the  magnitude  of  this  influence.  The  relation 
between  the  two  is  so  close  that  the  typhoid  death-rate 
has  been  often  used  as  an  index  of  the  quality  of  the 
water.  Generally  speaking,  it  is  safe  to  do  this ;  a  very 
low  death-rate  indicates  a  pure  water,  and  a  very  high 
rate,  a  contaminated  water.  Between  the  two  extremes 
there  is  a  range  of  death-rates  from  which  the  quality 
of  the  water  cannot  be  predicted,  and  the  aid  of  other 
data  has  to  be  invoked.  But,  taking  the  death-rates  of  a 
city  for  a  term  of  years,  and  studying  their  seasonal  and 
annual  variations  and  their  general  average,  one  can 
form  a  pretty  sound  conclusion  as  to  the  sanitary  quality 
of  the  public  water-supply. 

In  his  valuable  little  book  on  "Water  and  Public 
Health,"  published  in  1897,  Mr.  James  H.  Fuertes,  C.  E., 
gave  a  series  of  diagrams  in  which  the  relation  between 
typhoid  death-rates  and  various  water-supplies,  grouped 
according  to  the  character  of  their  source,  was  strikingly 
shown.     These  diagrams,  although  based  upon  data  ten 

228 


INFLUENXE    OF    PUBLIC   WATER-SUPPLIES.     229 

years  old,  are  just  as  applicable  to-day  as  they  were  then. 
One  of  them  is  reproduced  in  Fig.  24.  It  shows  the 
range  within  which  75  per  cent  of  the  death-rates  fell 
for  each  kind  of  water-supply,  and  may  be  considered 
as  marking  the  ordinar}-  limits  for  each  group,  although 
extreme  figures  both  above  and  below  those  given  were 
not  uncommon. 


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Diagram  Showing  tlie  Relation  bet-ween  the  Character  of  Water-supphes 
and  Typhoid  Fever  Death-rates.     (After  Fuertes.) 

Spring  waters,  well  waters,  and  filtered  surface  waters 
are  generally  considered  as  safe  sources  of  supply,  and 
the  diagram  shows  that  for  these  groups  the  death-rates 
range  from  about  5  to  25  per  100,000,  the  average  being 


230 


TYPHOID    FEVER. 


somewhere  between  15  and  20.  Supplies  from  upland 
streams,  impounding  reservoirs,  and  from  large  lakes 
and  rivers,  are  insecure  in  quality;  and  the  corresponding 
death-rates  range  from  about  15  to  about  55,  and  average 
about  35  per  100,000.  Supplies  which  are  conspicuously 
contaminated  may  have  death-rates  anywhere  from  40  up 
to  100  or  more.  No  hard  and  fast  lines  can  be  drawn 
between  the  different  groups,  as  the  potency  of  other 
causes  than  water  has  to  be  considered  in  each  case, 

DEATH-RATE  PER  100,000 
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Diagram  Showing  the  Ordinary  Range  of  Typhoid  Fever  Death-rates 
in  Cities  having  Contaminated  and  Uncontaminated  Water-supplies. 


but  it  is  commonly  assumed  that  in  the  northern  parts  of 
the  United  States  a  continued  typhoid  death-rate  above 
20  per  100,000  indicates  that  the  public  water-supply 
is  of  questionable  purity,  while  a  continued  death-rate 
below  15  indicates  safety.  In  the  Southern  states  the 
dividing  lines  would  have  to  be  placed  at  a  somewhat 
higher  figure,  as  the  influence  of  other  factors  is 
greater. 

If  a  good  water-supply  means  a  low  death-rate,  and  a 
bad  water-supply  means  a  high  death-rate,  one  would 


INFLUENCE   OF  PUBLIC  WATER-SUPPLIES.     231 

expect  to  find  that  when  a  city  changed  its  supply  from  a 
polluted  river  to  that  of  driven  wells,  or  constructed 
filters  to  purify  a  contaminated  water,  this  would  be 
followed  by  a  lessened  prevalence  of  typhoid  fever. 
This  is  just  what  has  been  happening  on  all  sides  during 
the  last  two  decades,  and  it  is  to  improved  water-supplies 
more  than  to  anything  else  that  the  recent  reductions  in 
typhoid  fever  have  been  due.  A  few  examples  will 
sufficiently  illustrate  this: 

Cities  which  have  changed  their  Source  of  Supply. 

Frankfort-on-the-Main,  Germany.  Frankfort-on-the 
Main  introduced  a  public  water-supply  in  1872.  Prior 
to  that,  there  had  been  no  general  supply,  and  private 


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The  Curves  Marked  "  Sewers  "  and  "  Water  "  Show  the  Percentage  of 
Houses  Joined  to  the  Sewers  and  Water  Mains,  Frankfort-on-the- 
Main,  Germany.     (After  Fuertes.) 


weUs  had  been  the  only  source.  W.  H.  Lindley,  C.E., 
has  shown  the  effect  of  this  new  supply  on  the  health 
of  the  city  by  a  diagram  (Fig.  26)  which  is  self- 
explanatory. 


232 


TYPHOID    FEVER. 


Newark,  NJ.  In  1892,  Newark,  N.J.  changed  its 
source  of  water-supply  from  the  polluted  Passaic  River 
to  the  Pequannock  River,  an  upland  supply,  utilized 
by  the   construction  of   a  series   of  large   impounding 

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'-yx 

^  ^ 

^ 

PASSAIC  RIVErI                        1 

PEQUANNOCK  RIVER 

'<^ 

J^ 

'■- 

Mill!    I 

1 

III 

0 

00 

oc 

CO 
CO 

eg 

CO 

00 

CO 

S2 

CO 

oc 

oc 
a 

CC 

oc 

00 

CO 

CO 

00 
a 

CC 
00 

0 

CD 
CO 

ot 

01 
a 

CO 
CO 

cn 
00 

LO 

cn 

CO 

CO 

01 

00 

1^ 
00 

00 
00 

0 
en 
00 

0 
0 
01 

0 
cn 

0 

0 

CO 
0 

z 

01 

10 
0 
cn 

U3 
0 

cn 

r- 
0 

Fig.  27. 

Diagram  Showing  the  Relation  between  the  Public  Water-supply  and 
the  Typhoid  Fever  Death-rates  in  Newark,  N.J. 


The  population  on  this  watershed  is  sparse;  there  are 
no  large  towns  on  it,  and  the  drainage  of  the  individual 
houses  near  the  tributary  streams  is  carefully  looked 
after.  The  change  in  the  typhoid  death-rate  resulting 
from  the  use  of  this  better  water  is  shown  in  Fig.  27. 

In  February,  1899,  during  a  spell  of  very  cold  weather, 
a  water  famine  was  threatened  and  it  became  necessary 
to  augment  the  supply  by  pumping  water  from  the  old 
Passaic  River  supply  into  the  low  service  system.  This 
was  done  for  about  a  week,  and  resulted  in  about  four 


ixfllenxe  of  public  water-supplies.    233 

hundred  cases  of  typhoid  fever  and  about  fifty  deaths,  — 
practically  all  of  them  within  the  low  service  district. 
Jersey  City.  During  the  last  ten  or  fifteen  years  Jersey 
City  has  had  four  different  sources  of  water-supply. 
For  some  time  prior  to  1896  the  water  was  taken  from 


NEAR  THE  CITY 


RIVER  AT 
LITTLE  FALLS 


Fig.  28. 

Diagram  Shov,-ing  the  Relation  between  the  Water-supply  and  the 
Typhoid  Death-rates  in  Jersey  City,  X.  J. 


the  Passaic  River  at  Belleville,  near  the  city,  at  a  point 
where  it  was  considerably  polluted.  Since  1896  the 
supply  has  been  taken  from  three  upland  sources. 
Between  1896  and  1901  the  Pequannock  water  was  used; 
between  1901  and  1904  the  supply  was  obtained  from  the 


234 


TYPHOID   FEVER. 


Passaic  River  at  Little  Falls.  Since  then,  the  Rockaway 
River  water  from  the  Boonton  reservoir  has  been  used. 
In  no  case  has  the  water  been  filtered.  The  diagram 
shows  that  since  the  abandonment  of  the  Passaic  River 


170 
.160 
150 
^140 
8130 
§120 
alio 
SlOO 
^  90 

<  80 
I  70 

<  60 
111 

o  50 

%'' 
X   30 

^    20 

10 

0 


m 

m. 

y/} 

rrr 

/// 

Va 

'// 

' 

LOVVELL 

1 — 

M 

AS 

3. 

' 

'V/ 

-T- 

u 

' 

! 

— 1 

--I— r— , 

;    Y' 

1    ;    "    i    i    ;    i    i    ' 

i              '   ^    :!'';'!    .. 

■    '                    '    '          •          I     ■     '     '     '' 

^ 

^77? 

777/ 

-m 

S3 

— 

— 

r 

'  \'i  \  :  .'  r\" 

•     I     '     .     '     ' 

--\'-- 

-+— 

1 

M 

ER 

^IIV 

AC   RIVE 

\  V 

VA1 

•EF 

G 

RO 

JN 

3  V 

VA" 

rEF 

i 

m^4r\    l,i 

1    'ly/. 

m 

1 

M 

^ 

1       1      1 

_ 

UNFILTERED 


Fig.  29. 

supply  the  typhoid  fever  death-rate  in  the  city  has  been 
lower  than  formerly,  although  there  was  an  outbreak 
in  1898  which  was  due  to  a  temporary  return  to  the  old 
Passaic  River  supply.  Except  for  this  year  the  fluctua- 
tions in  the  typhoid  fever  death-rate  of  the  city  have  not 
been  large.  The  Rockaway  source,  however,  is  not  as 
safe  as  the  other  upland  sources,  and  since  its  use  there 
has  been  a  slight  increase  in  typhoid  fever  in  the  city. 


TXFLUE^XE   OF  PUBLIC  WATER-SUPPLIES.     235 

Cleveland,  Ohio.  The  city  of  Cleveland  takes  its 
water-supply  from  Lake  Erie.  Prior  to  1904  the  point 
of  intake  was  only  1.5  miles  from  the  shore,  and  was 
subject  to  occasional  severe  contamination  from  the 
city's  sewage;  but  in  the  year  mentioned  a  new  intake 
was  put  in  service,  and  the  water  is  now  taken  at  a 
distance  of  four  miles  from  the  city.  The  change  in  the 
supply  resulted  in  an  immediate  reduction  in  the  typhoid 
death-rate.  This  has  been  already  referred  to.  (See 
Fig.  18,  p.  171. J 

Lowell,  Mass.  Profiting  by  the  lesson  of  the  epidemics 
of  1890  and  1892,  the  city  of  Lowell,  in  1896,  abandoned 
the  use  of  the  polluted  ]\Ierrimac  River  and  obtained  a 
supply  from  driven  wells.  The  change  to  the  new  supply 
was  somewhat  gradual,  and  the  reduction  in  the  death- 
rate  was  correspondingly  gradual. 

Cities  li'Jdch  retained  their  Old  Supplies,  hut 
Constructed  Filters. 

Zurich,  Switzerland.  The  water-supply  is  taken 
from  Lake  Zurich,  near  the  outlet,  not  far  from  the 
heart  of  the  city.  Xo  public  sewers  discharge  into 
the  lake,  but  the  water  is  necessarily  more  or  less  pol- 
luted. Prior  to  1886  the  typhoid  fever  death-rate  in 
the  city  had  been  high,  but  in  that  year  new  filters 
were  constructed  and  this  immediately  reduced  the  rate 
to  a  low  figure. 

Hamburg,  Germany.  Hamburg  is  chiefly  famous 
among  sanitarians  for  the  great  cholera  epidemic  of 
1892.  At  that  time  filters  were  under  construction 
for  the    purification    of    the   water-supply,    which   was 


236 


TYPHOID    FEVER. 


taken  from  the  Elbe  River.  The  works  were  con- 
structed in  1893,  and  since  then  the  health  of  the  city 
has  greatly  improved. 


180 

170 

160 

150 

140 

130 

120 

110 

100 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 


m 


mww/M 


m 


ZURICH, 


SWITZERLAND, 


c. 

OLD  FILTERS 


NEW  FILTERS 


Fig.  30. 


Lawrence,  Mass.  Taught  by  the  sad  experience  of 
several  epidemics,  the  city  of  Lawrence  constructed  a 
filter  plant  in  1893.  This  city  has  the  distinction  of 
being   the    first    in  this   country  to    take    up   filtration 


INFLUENCE  OF  PUBLIC  WATER-SUPPLIES.     237 


UNFILTERED  FILTERED 


Fig.  31. 

Diagram  Showing  the  Relation  between  the  Water-supply  and  the 
Typhoid  Death-rates  of  Hamburg,  Germany. 


CM    CO     ^    10    (o    r« 


Fig.  32. 


238  TYPHOID    FEVER. 

along  modern  lines,  and  the  credit  belongs  to  the  Mas- 
sachusetts State  Board  of  Health.  The  particular  type 
of  the  filter  resulted  from  the  experiments  made  at 
the  world-renowned  Lawrence  Experiment  Station,  with 
which  some  of  the  best-known  American  sanitary  engi- 
neers have  been  connected. 

The  construction  of  this  filter  brought  an  immediate 
reduction  in  the  typhoid  fever  death-rate.  The  filter 
gradually  became  outgrown,  however,  and  its  efficiency 
correspondingly  decreased.  At  the  present  time  (1908) 
it  is  being  enlarged. 

The  original  Lawrence  filter  differed  from  those  which 
have  since  been  built.  Among  other  things,  it  had  no 
roof,  and  in  consequence  there  has  been  more  or  less 
trouble  in  cleaning  the  sand  beds  in  the  winter  on  account 
of  ice.  The  filter  was  designed  also  to  operate  inter- 
mittently instead  of  continuously. 

Albany,  N.Y.  The  filter  at  Albany,  constructed  in 
1889  to  purify  the  water  of  the  Hudson  River,  polluted 
by  the  sewage  of  Troy,  Cohoes,  Schenectady,  and  many 
other  cities,  represents  the  type  of  filter  which  has  since 
been  largely  used  in  this  country.  It  followed  European 
practice  more  closely  than  that  at  Lawrence.  It  is  a 
"sand  filter,"  or  a  "slow  sand  filter,"  as  it  is  often 
called,  and  consists  of  a  large  area  of  sand  four  feet 
deep  which  rests  on  a  foundation  of  gravel  and  coarse 
stones,  embedded  in  which  are  collecting  drains.  This 
sand  area,  which  covers  5.6  acres,  is  divided  into 
several  "beds,"  which  may  be  separately  controlled. 
The  filter  material  rests  on  a  concrete  floor,  and  is 
covered  with  a  groined  arch  roof,  supported  on  piers 


INFLUENCE  OF  PUBLIC  WATER-SUPPLIES.     239 

which   pass   down   through   the   sand   bed.     The   river 
water,  after  first  passing  through  a  large  settling  basin, 


UNFILTERED 


FILTERED 
©4      C3      ■*      10      «o      r» 


Fig.  33- 

Diagram   Showing  the  Relation  between  the  Water-supply  and  the 
Typhoid  Death-rates  of  Albany,  N.Y. 


flows  over  the  sand,  filters  down  through  it  at  a  slow 
rate,    and    collects    in    the    underdrains.     The    process 


240 


TYPHOID    FEVER. 


removes,  on  an  average,  something  like  99  per  cent  of 
the  bacteria,  and  any  typhoid  germs  present  are  pre- 
sumably removed  in  the  same  proportion. 


100 


80 


60 


40 


20 


i 

i 


i 


^ 


#^P-^ 


BINGHAIV1T0N,N.Y. 


Y  9-/y/'y  ^\^',  v//' 


SUSQUEHANNA  RIVER  WATER 

I    r_i 


UN  FILTER  ED 


//>/-'/^///.A'//y 


1 


U>  h-.COOlo'-PJW*     -to      <£>       h- "   00      <J>      o 


OJ  "  CO  .  ,"!^     10      (O      t~ 


Fig.  34. 

Diagram  Showing  tlie  Relation  between  tlie  Water-supply  and  the 
Typhoid  Fever  Death-rates  of  Binghamton,  N.Y. 

When  the  people  of  Albany  drank  the  Hudson  River 
water  raw,  typhoid  fever  was  rampant;  but  the  filter  put 
a  stop  to  this,  and  caused  a  very  sudden  drop  in  the  death- 
rate.  This  filter  is  now  working  up  to  its  capacity,  and 
alterations  are  being  made  with  the  object  of  increasing 
its  output.  In  considering  the  typhoid  death-rate  since 
1900,  it  ought  to  be  noted  that  the  filtered  Hudson  River 
water  does  not  furnish  the  entire  supply  of  the  city. 
Part  of  the  water  used  is  taken  from  a  surface  supply 


IXFLUENXE   OF  PUBLIC  WATER-SUPPLIES.     24 1 


*io^r~-QOCT>gr-c-inTfintD 


200 


180 


160 


140 


H  100 


iS    80 


40 


20 


W^ 


I 


WATERTOWN, 


-^^ 


N.Y. 


^^ 


WW^: 


BLACK  RIVER  WATER 


.//^., ,  '-'Ya 


UN  FILTERED  FILTERED 

Fig.  35. 

Diagram  Sho-wing  the   Relation  bet-n-een  the   Public  Water-supply 
the  Typhoid  Death-rates  in  Watertown,  X.Y. 


and 


242      .  TYPHOID    FEVER. 

which  is  not  fihered,  and  the  sanitary  quality  of  which 
is  not  secure. 

Binghamton,  N.Y.  The  water-supply  of  Bingham- 
ton,  N.Y.,  is  taken  from  the  Susquehanna  River  and 
is  used  without  any  storage  whatever.  The  water  is 
often  muddy  and,  worse  than  this,  it  is  contaminated. 
In  1902  a  filter  plant  was  constructed.  It  is  of  the 
mechanical  type,  using  alum  as  a  coagulant.  Almost 
immediately  after  this  installation  there  was  a  decided 
decrease  in  the  amount  of  typhoid  fever,  as  well  as  of 
winter  cholera,  which  up  to  that  time  had  been  quite 
prevalent.  During  the  last  four  or  five  years  the  typhoid 
fever  rate  has  been  exceptionally  low. 

Watertown,  N.Y.  Watertown  takes  its  water-supply 
from  the  Black  River,  a  stream  which  is  considerably 
polluted  by  paper-mill  refuse,  and  with  the  sewage  of 
several  large  communities.  For  many  years  the  typhoid 
fever  rate  was  high,  and  some  years  it  was  exces- 
sively high.  During  1904  there  was  a  severe  epidemic 
during  which  about  six  hundred  people  were  made 
ill  and  nearly  fifty  people  died.  A  iilter  plant  was 
under  construction  when  this  epidemic  occurred,  but 
it  was  not  put  in  service  until  September,  1904.  Since 
then  the  typhoid  fever  death-rate  has  been  very  much 
lower. 

Paterson,  N.J.  Paterson,  N.J.,  is  one  of  a  group  of 
communities  supplied  with  water  by  the  East  River 
Water  Company.  The  source  of  the  supply  is  the 
Passaic  River  at  Little  Falls.  Until  1902,  it  was  used 
without  filtration,  but  during  that  year  a  mechanical 
filter  was  put  in  service,  and  since  then  the  typhoid  fever 


IXFLUENXE   OF  PUBLIC  WATER-SUPPLIES.     243 

rate  has  been  much  lower.  The  other  communities 
supplied  by  the  same  company  show  corresponding 
reductions  in  the  typhoid  fever  death-rates. 


FILTERED 
cj      CO       •*     10      o      r^ 


Fig.  36. 

Diagram  Showing  the  Relation  between  the  Water-supply  and  the 
T}-phoid  Death-rates  of  Paterson,  N.J. 


Paris,  France.  Filtered  water  has  been  recently 
introduced  into  one  of  the  suburbs  of  Paris.  Fig.  37 
illustrates  the  improvements  in  the  typhoid  fever  death- 
rates  that  have  been  produced  by  it.  Until  within  a 
comparatively  recent  period  French  sanitary  engineers 
have  favored  ground  water  rather  than  liltered  water, 
but  recently  there  has  been  a  changing  sentiment 
and  the  tendency  now  is  towards  the  greater  use  of 
filtration. 

St.  Louis,  Mo.  The  water-supply  of  St.  Louis  is  taken 
from  the  Mississippi  River,  just  below  where  the  Missouri 


244 


TYPHOID    FEVER, 


enters.     The  water  is  intensely  muddy  at  times,  and  is 
never  clear.    Mark  Twain  or  some  one  else  once  said  that 


TYPHOID  MORBIDITY 
PER  100,000 


TYPHOID  MORTALITY 
PER  100,000 


I   I 


il 
J  J 


4 

1 
Si 

s| 

-  I 


i 


<  « 


I 


il 

il 


J 


1 


^ 


i 


I 


i_i 


si 

si 

il  ;;: 

qI  2 

s|  ^ 

il  ^ 


^1 


Fig.  37. 

Effect  of  Filtration  in   Reducing  the  Typhoid  Fever  Death-rates  and 
the  General  Mortality  in  a   Suburb  of  Paris.     (After  Chabal.) 


when  the  wind  blew  over  the  water  it  raised  a  dust. 
The  water  is  not  filtered,  but  for  many  years  has  been 
passed  through  settling  basins,  where  8o  or  90  per  cent 


INFLUENCE  OF   PUBLIC  WATER-SUPPLIES.     245 

of  the  mud  was  removed.  In  1904  this  process  of  sedi- 
mentation was  rendered  somewhat  more  efficient  by 
adding  two  chemicals  to  the  water  before  it  entered  the 
basins,  namely,  sulphate  of  iron   (copperas)  and  lime. 


O       r-      ct       <o 


ta     ^     r^     00      oi 


r-      N     W     ^*     10   "'«o      r^ 


PLAIbl.SEDIMEt^XATION 


CHEMICAL 
PRECIPITATION 


Fig.  38. 

Diagram  Showing  the  Relation  between  the  Water-supply  and  the 
Typhoid  Death-rates  in  St.  Louis,  Mo. 


Since  then  the  water  in  the  city  has  been  clearer  and 
more  healthful,  although  the  quality  is  still  far  from  that 
of  the  effluent  of  a  good  filter  plant. 

The   improvement   in   the   water  seems   to   have  re- 


246 


TYPHOID    FEVER. 


duced    the    typhoid    death-rate,    which   had    begun  to 

increase    after  the   opening   of  the   Chicago    Drainage 

Canal. 

.    Philadelphia,  Pa.     The  water-supply  of   Philadelphia 

is    taken    from    the  Schuylkill    and   Delaware  Rivers. 


1000 


;8oo 


PHILADELPHIA,  PA. 

DIAGRAM  SHOWING  THE  POPULATION, 

NUMBEB,  OF  DEATHS  FROM  TYPHOID  FEVER, 

AND  THE 

TYPHOID  DEATH  RATES,  BY  YEARS. 


roo 


u_500 


800,000 


600,000 


Fig.  39. 

There  are  several  different  intakes.  An  extensive 
filtration  system  is  being  installed.  Some  of  the  fihers 
are  in  operation,  but  many  delays  have  occurred  and  a 
large  part  of  the  city  is  still  using  unfiltered  water. 
Already,  the  benefits  of  filtration  have  been  seen  in  those 


INFLUENCE  OF   PUBLIC  WATER-SUPPLIES.     247 

sections  of  the  city  which  have  filtered  water,  but  the 
disease  has  been  so  prevalent  in  the  other  sections  of 
the  city  supplied  with  raw  water  that  the  death-rates  as 
a  whole  have  not  decreased. 

Experience  as  to  the  Benefit  of  Filtration.  Experience 
has  shown  that  filtration  affords  adequate  protec- 
tion. One  by  one  the  cities  of  America  are  falling 
into  line  and  taking  up  this  important  work.  In 
his  paper  before  the  International  Engineering  Con- 
gress in  St.  Louis,  Hazen  gave  a  table  showing  the 
progress  of  filtration,  as   follows: 

TABLE  SHOWING  THE  EXTENT  OF  FILTRATION  IN  THE 
UNITED    STATES. 


Year. 

Total  Urban 
Population  in 

the  U.  S. 

(Towns  above 

2,500). 

Population 

SuppUed  with  Filtered   Water. 

Percentage 
of  Urban 
Popula- 
tion Sup- 
plied with 
Filtered 
Water. 

Sand  Fil- 
ters. 

Mechanical 
Filters. 

Total. 

1870 
1880 
1890 
1900 
1904 

13,300,000 
21,400,000 
29,500,000 
32,700,000 

None 

30,000 

35>ooG 

360,000 

560,000 

None 

275,000 
1,500,000 
2,600,000 

None 
30,000 

310,000 
1,860,000 
3,160,000 

0 

0.23 

1-45 

6-3 

9-7 

Even  to-day  these  figures  are  out  of  date,  and  the  pro- 
portion of  the  population  supphed  with  filtered  water,  or 
contemplating  the  early  adoption  of  filtration,  is  greater 
than  that  given.  This  movement  is  bound  to  go  on 
until  every  city  has  either  a  ground  water  naturally 
filtered,  or  a  surface  water  artificially  filtered.     Clean 


248  TYPHOID    FEVER. 

and  wholesome  water  every  self-respecting  municipality 
is  bound  to  have.^ 

Cities  where  the  Introduction  of  Filters  has  not  been  Fol- 
lowed by  a  Material  Reduction  in  the  Typhoid  Fever 
Death-rate. 

Youngstown,  Ohio.  The  water-supply  at  Youngs- 
town  is  taken  from  the  Mahoning  River.  While  origi- 
nally of  fairly  satisfactory  quality,  its  pollution  gradually 
increased  and  gave  rise  to  a  steadily  increasing  typhoid 
fever  death-rate  in  the  city.  In  August,  1905,  a  mechani- 
cal filter  was  introduced.  This  lowered  the  rate  some- 
what, but  not  as  much  as  was  expected.  An  outbreak 
occurred  during  the  early  part  of  1906,  which  was  studied 
carefully  by  Mr.  Paul  Hansen  for  the  Ohio  State  Board 
of  Health.  He  found  that  out  of  153  cases  contracted  in 
the  city,  93  resided  in  houses  where  there  were  no  sewers 
and  no  public  water-supply,  while  109  claimed  to  have 
used  well  water  only.  Many  of  the  houses  were  in  a 
poor  sanitary  condition.  Investigation  showed  that 
this  outbreak  was  not  due  to  the  use  of  the  city  water, 
then  being  filtered,  but  rather  to  the  use  of  polluted 
wells,  and  to  direct  contact,  including  transmission  by 
flies.     In  1907  the  disease  was  less  prevalent. 

Washington,  D.C.  The  city  of  Washington  takes 
its  water-supply  from  the  Potomac  River  at  Great  Falls, 
about  14  miles  above  the  city.  For  many  years  it  passed 
through  two  reservoirs,  the  Dalecarlia  and  the  George- 

*  Readers  interested  in  the  problems  of  public  water-supply  should 
consult  Mr.  Hazen's  recent  book  on  "  Clean  Water  and  How  to 
Get  it." 


INFLUENCE   OF  PUBLIC  WATER-SUPPLIES.     249 


iot0h-esnov^cQ       eo-^-iDtoK 


UNFILTE-aED 


FILTERED 


Fig.  40. 

Diagram  Showing  the  Relation  between  the  PubHc  Water-supply  and 
the  Typhoid  Fever  Death-rates  in  Youngstown,  Ohio. 


250 


TYPHOID    FEVER. 


INFLUENCE  OF   PUBLIC  WATER-SUPPLIES.      251 

town  Reservoir.  In  1902  a  third  reservoir  and  settling 
basin,  known  as  the  Washington  City  Reservoir,  was  put 
in  service.  In  October,  1905,  a  filtration  plant  of  the 
most  modern  construction  was  put  in  operation,  so  that 
at  the  present  time  the  Potomac  water  passes  through 
three  settling  basins  and  a  filter  before  it  is  delivered  to 
the  consumers. 

For  many  years  the  typhoid  fever  death-rate  in  Wash- 
ington had  been  high,  and  it  was  confidently  expected 
that  after  the  introduction  of  filtered  water  the  rate  would 
materially  decrease.  During  1906,  however,  the  death- 
rate  increased  slightly  instead  of  decreasing.  As  it 
did  not  seem  possible  that  the  filter  could  be  at  fault, 
an  extensive  investigation  of  the  subject  was  undertaken 
by  a  commission  consisting  of  Dr.  M.  J.  Rosenau,  L.  L. 
Lumsden,  and  Joseph  H.  Kastle.  A  voluminous  report 
was  published  in  1907  which  in  some  respects  is  one  of 
the  most  instructive  reports  on  the  subject  of  typhoid 
fever  that  has  appeared  in  recent  years.  Although  this 
investigation  was  most  exhaustive,  yet  the  data  collected 
failed  to  establish  the  cause  of  the  greater  part  of  the 
cases  which  occurred  in  the  city.  Indications  pointed 
strongly,  however,  to  milk  as  being  the  chief  source  of 
the  infection,  and  this  was  emphasized  by  Professor 
Sedgwick,  and  Mr.  Theodore  Horton,  who  also  investi- 
gated the  prevalence  of  the  fever. 

Looking  back  over  the  history  of  typhoid  fever  in 
Washington  the  data  seem  to  indicate  that  not  for  many 
years  has  the  water-supply  played  the  major  part  in  the 
causation  of  this  disease,  for  it  had  been  already  sub- 
jected  to   a   partial  purification,   namely,   that   due   to 


252  TYPHOID    FEVER. 

sedimentation  and  storage  in  the  three  reservoirs.  From 
1897  up  to  1902,  when  the  Washington  City  Reservoir 
was  buik,  the  typhoid  fever  rate  had  been  gradually 
increasing,  especially  during  the  winter  months,  but 
between  1902  and  1905  there  was  a  falling  off  in  the 
rate  which  may  be  attributed  in  part,  at  least,  to  the 
greater  purification  brought  about  by  the  increasing 
use  of  the  additional  sedimentation. 

If,  then,  the  water  had  played  but  little  part  in 
the  causation  of  the  disease  before  the  filter  was  con- 
structed, it  could  not  be  expected  that  the  operation  of 
the  filter  would  result  in  any  material  reduction  in  the 
death-rate. 

A  study  of  the  seasonal  distribution  of  typhoid  fever 
in  Washington  shows  that  the  disease  is  chiefly  one  of 
summer,  and  that  it  has  not  for  many  years  been  preva- 
lent to  a  considerable  extent  in  the  winter  and  spring. 
This  fact,  taken  in  connection  with  an  abnormally  large 
proportion  of  cases  among  children,  points  to  the  impor- 
tant influence  of  milk  and  direct  contagion  in  the  spread 
of  the  disease  in  that  city.  During  the  summer  of  1907 
there  was  a  decrease  in  the  amount  of  typhoid  fever  in 
Washington,  due,  in  part,  no  doubt  to  the  activities 
resulting  from  the  investigation  referred  to. 

Cities  which  have  made  Slight  Changes  in  the  Character 
of  their  Water-Supplies. 

Boston,  Mass.  For  many  years  Boston's  water-supply 
was  derived  from  the  Sudbury  and  Cochituate  water- 
sheds. These  sources,  while  subject  to  considerable 
pollution,    had   been    carefully   treated,    the   sewage   of 


INFLUENCE  OF  PUBLIC  WATER-SUPPLIES.     253 

several  large  communities  had  been  diverted,  filter  beds 
had  been  built  to  purify  the  water  of  certain  contami- 


Nouvnn^od 


r     -o  m 


aaA3si  QioHdAJ.  woad  sHivaa  do  uaawoN 


Q 


nated  brooks,   cesspools  and  privy  nuisances  adjacent 
to  the  streams  had  been  abated,  and  a  careful  patrol 


2  54  TYPHOID    FEVER. 

maintained.  Yet  the  population  was  there.  It  was 
776  per  square  mile  on  the  Sudbury  systems,  and  282 
per  square  mile  in  the  Cochituate  system,  so  that  in  spite 
of  the  sanitary  reforms  and  the  natural  benefits  of  the 
large  storage  reservoirs  the  typhoid  fever  death-rate  in 
Boston  was  not  as  low  as  it  should  be. 

In  1898  the  new  supply  from  the  Nashua  River, 
impounded  in  the  great  Wachusett  Reservoir,  was  intro- 
duced. The  Nashua  watershed  is  much  less  populated 
than  the  Sudbury  and  Cochituate  areas,  —  the  number 
of  inhabitants  per  square  mile  being  only  49.  The 
storage  in  the  reservoir  is  also  longer.  Since  this  new 
supply  has  been  in  use  there  has  been  a  gradual  drop  in 
the  typhoid  death-rates  which  may  be  attributed,  in 
part  at  least,  to  the  use  of  better  water.  As  the  new 
supply  yields  a  water  less  colored  and  less  affected  with 
odors  due  to  alg£e,  it  has  been  used  to  the  partial  ex- 
clusion of  the  old  sources.^  When  the  consumption 
increases,  however,  so  that  it  is  necessary  to  once  again 
draw  heavily  on  the  old  supplies,  and  this  must  happen 
some  time,  it  will  be  surprising  if  the  people  of  Boston 
remain  content  to  be  served  with  water  without  filtration. 
Boston  has  been  for  many  years  a  leader  in  sanitary 
reforms;  it  is  not  likely  that  she  will  allow  herself  to  be 
outstripped  by  the  other  large  cities  in  the  protection  of 
her  water-supply. 

New  York  City.  New  York  City  has  been  for  many 
years  supplied  with  water  from  the  Croton  River.  At 
first  there  was  a  single  reservoir  known  as  the  Old  Croton 

*  During  the  last  few  years  the  Wachusett  Reservoir  has  furnished 
about  two-thirds  of  the  supply. 


INFLUENCE  OF  PUBLIC  WATER-SUPPLIES.     255 

Lake.     Now  there  are  a  dozen  or  so  reservoirs  on  the 
various  tributary  streams,  and  the  Old  Croton  Lake  has 


Noiivmdod 


9061 


0681 


9881 


0881 


9Z.81 


0^81. 


U 


(U     o 

>  >i 


•S    c 


fH       D 


HHABd  QioHdAx  lAioud  sHiV3a  do  aaawfiN 


been  lost  in  the  new  reservoir  created  by  the  construction 
of  the  great  dam.     While  the  general  source  remains  the 


256  TYPHOID    FEVER. 

same  throughout,  the  methods  of  utilizing  the  water  have 
been  subject  to  change.  A  study  of  the  typhoid  fever 
death-rates  of  the  city  is  interesting  in  several  respects. 
In  1 869-1 870  there  were  severe  droughts  during  which 
the  rate  was  high.  From  that  time  the  rate  fell  gradu- 
ally to  1879.  Then  followed  some  very  dry  years  during 
which  the  typhoid  fever  rate  increased  materially.  Be- 
tween 1883  and  1897  the  rate  steadily  decreased.  This 
may  be  attributed  to  the  constantly  increasing  storage 
capacity,  to  the  generally  more  favorable  meteorological 
condition,  but  especially  to  the  expedients  adopted  to 
protect  the  water-supply  from  pollution.  In  1888  the 
board  of  health  established  rules  and  regulations 
relating  to  the  pollution  of  the  watershed,  and  in  1893 
expensive  purchases  of  land  and  buildings  were  made 
along  the  courses  of  the  streams  and  around  the  reser- 
voirs. In  1893  a  sewage  purification  plant  was  estab- 
lished on  the  watershed  at  Brewster.  The  increase  in 
1898  was  due  to  the  soldiers  returning  from  Cuba  after 
the  Spanish  War.  During  the  last  few  years  there  has 
been  a  further  slight  reduction  in  the  death-rate,  which 
may  be  due  in  part  to  the  greater  care  exercised  in  pre- 
venting contamination  from  small  sources. 

It  must  be  remembered,  that  in  a  great  city  like  New 
York,  many  causes  of  typhoid  fever  are  in  operation, 
and  these  are  difficult  to  trace.  Nevertheless,  the 
fluctuations  in  the  typhoid  fever  curve  do  appear  to 
reflect  to  some  extent  the  sanitary  quality  of  the  public 
water-supply. 

Brooklyn,  N.Y.  The  water-supply  of  Brooklyn  is 
taken  from  Long  Island,  partly  from  driven  wells  and 


INFLUENCE  OF  PUBLIC  WATER-SUPPLIES.     257 


506  L 


0061 


S68I. 


0681 


9881 


0881 


3^81. 


0Z81. 


NOIlVnndOd 


S  s  °  ■■ 

Q 

> 

u 

c 

§     p 

■* 
■^ 

> 
a) 

2 

t^ 

0 

§  *  S  0 

0 

IS 

a3A3j  aioHdAx  woHd  SHivHO  do  aaawnN 


partly  from  small  streams.  Twenty  years  ago  the 
greater  part  of  the  water  was  surface  water;  to-day  the 
larger  portion  is  ground  water. 

For    a    generation    the    typhoid    fever    death-rate    in 


258  TYPHOID    FEVER. 

Brooklyn  has  fluctuated  between  comparatively  narrow- 
limits  and  has  shown  much  smaller  fluctuations  than  in 
most  of  the  cities  of  the  country.  It  has  also  been  com- 
paratively low.  Nevertheless  a  study  of  the  fluctuations 
in  these  rates  seems  to  correspond  with  the  changes 
which  have  been  made  in  the  source  of  water-supply. 
Between  1870  and  1880  the  death-rate  gradually  fell, 
probably  because  during  this  time  hundreds  of  polluted 
wells  throughout  the  city  were  closed  by  order  of  the 
board  of  health.  Between  1880  and  1890  the  rate 
increased.  During  this  time  the  draft  upon  the  water- 
shed was  constantly  increasing,  while  certain  streams 
somewhat  more  polluted  than  those  previously  in  use 
were  added  to  the  supply.  From  1890  to  1895  the  rate 
dropped  again.  Several  causes  probably  contributed 
to  this  decrease.  The  new  watershed,  first  drawn  upon 
in  1 89 1,  added  a  considerable  volume  of  relatively  pure 
water  to  the  supply;  in  1892  the  Ridgwood  Reservoir  was 
enlarged,  while  during  the  years  1893-5  arrangements 
were  made  for  panning  the  water-closets  in  the  village 
of  Hempstead  along  one  of  the  important  streams. 
About  that  time  also  some  of  the  more  polluted  sources 
near  the  city  were  cut  off. 

The  increase  in  1898  was  due  to  the  Spanish  War  and 
the  further  increase  in  the  next  few  years  was  due  proba- 
bly to  the  greater  draft  upon  the  watershed.  Recently 
the  rate  has  been  falling  slightly,  and  this  decrease 
has  been  coincident  with  the  establishment  of  several 
small  filter  plants  to  purify  the  most  threatened 
surface  waters  and  the  addition  of  new  sources  of 
ground  water. 


INFLUENCE  OF  PUBLIC  WATER-SUPPLIES.     259 

Baltimore,  Md.  The  water-supply  of  Baltimore  is 
impounded  surface  water  used  without  filtration.  The 
drainage  area  is  about  350  square  miles  and  the  popu- 
lation upon  it  about  32  per  square  mile.  A  thorough 
system  of  sanitary  control  is  said  to  be  in  force.     The 


500,000 


400,000 


300,000 


200,000  a. 


100,000 


Fig.  45. 

Diagram  Showing  the  Number  of  Deaths  from  Typhoid  Fever  and  the 
Corresponding  Death-rates  for  Baltimore,  Md. 


city  has  no  general  sewerage  system  for  house  drainage: 
slops  for  kitchen,  bath-tubs  and  laundry  waste  flow  in 
gutters  all  over  the  city,  and  the  night  soil  from  thous- 
ands of  cess  pools  is  carried  in  scows  and  teams  to 
truck  farms  and  used  on  gardens. 


260  TYPHOID    FEVER. 

Under  these  circumstances  the  typhoid  fever  situa- 
tion in  the  city  is  much  better  than  one  might  expect. 

Cities  Supplied  with  Water  Imperfectly  Filtered. 

If  a  fiher  is  to  give  good  service  and  so  purify  the  water 
that  the  public  will  be  adequately  protected,  it  must  be 
properly  designed  and  properly  operated.  A  good  many 
illustrations  might  be  mentioned  of  filters  which  have 
failed  to  do  the  work  expected  of  them  and  the  recital 
of  these  failures  has  sometimes  led  unthinking  people 
to  believe  that  all  filtration  was  unsafe.  But  it  must  be 
remembered  that  there  are  filters  and  filters.  Safety 
clutches  on  elevators  sometimes  fail  to  work,  yet  safety 
clutches  are  a  good  thing. 

Many  of  the  early  mechanical  filters  were  filters  only 
in  name;  they  strained  the  water,  but  did  not  to  any 
great  extent  remove  objects  of  microscopic  size,  —  con- 
sequently they  were  not  able  to  remove  the  typhoid 
bacilli,  or  to  render  an  infected  water  safe.  Filters  of 
this  kind  were  in  use  at  Augusta  and  at  Bangor,  Maine, 
during  the  epidemics  there. 

The  first  sand  filters  built  in  this  country  were  those 
at  Poughkeepsie  and  Hudson,  N.Y.  They  did  good 
service  for  many  years,  but  they  became  outgrown  in 
size,  and  the  pollution  of  the  Hudson  River  became 
greater  than  they  could  manage,  as  constructed,  so 
there  came  a  time  when  as  a  sanitary  safeguard  they 
were  not  a  complete  success.  When  the  flood  of  typhoid 
fever  came  down  the  valley  in  1892,  both  of  these  cities 
suffered,  but    they  undoubtedly  suffered  far  less  than 


INFLUENCE  OF  PUBLIC  WATER-SUPPLIES.      26 1 

they  would  have  if  no  fiher  at  all  had  been  in  use.  These 
filters  have  since  been  reconstructed  and  at  Pough- 
keepsie  a  new  sedimentation  basin  has  been  recently 
built. 

Like  all  other  structures,  filters  may  deteriorate,  parts 
may  wear  out,  and  they  may  become  outgrown.  Some- 
times these  repairs  and  enlargements  are  made  too  late. 
The  filter  at  Lawrence  was  outgrown  for  many  years 
before  additions  were  made.  There  are  many  old-type 
filter  plants  in  the  country  to-day  which  ought  to  be 
over-hauled,  or  replaced  by  modem  structures.  In 
building  filters  it  pays  to  build  well.  A  plant  suited  to 
the  local  conditions  will  do  better  work  and  last  longer 
than  the  filters  of  stock  pattern,  of  which  so  many  were 
■put  in  a  few  years  ago. 

Lorain,  Ohio.  The  water-supply  of  Lorain  is  taken 
from  Lake  Erie  at  a  point  where  it  is  considerably 
polluted  by  the  sewage  of  the  city,  which  it  receives 
through  the  Black  River.  In  1899  a  mechanical  filter 
was  put  in,  and  for  a  few  years  alum  was  used  as  the 
coagulant.  Then,  in  order  to  reduce  expenses,  an  iron 
sulphite  process  was  tried.  This  was  found  to  be 
unsatisfactor}%  and  during  its  use  the  strainer  system 
of  the  filter  was  practically  destroyed  by  the  action  of 
this  chemical.  Since  1903,  iron  sulphate  (copperas)  and 
lime  have  been  used. 

Before  the  introduction  of  the  filtered  water  the  typhoid 
fever  death-rates  were  very  high;  they  fell  at  once  on 
the  introduction  of  the  filter,  and  remained  low  for  the 
first  few  years  of  its  operation.  When  the  filter  got  out 
of  repair,  by  reason  of  the  damaging  effect  of  the  iron 


262 


TYPHOID    FEVER. 


o>      o»-e4W'r>n<Dt--,ooo>      o»-M«»i'io«ot^ 


LOR  A 


160 


140 


120 


oi  100 

UJ 


^    60 


N,  OHIO 


1 


#^. 


r^^T^ 


'm 


40 


^ 


20 


I       t — 


^ 


y//////{^//// 


m^ 


LAKE  ERIE 


-UNFILTERED- 


ALUM 
PROCESS 


IRON  IRON 

SULPHITE     SULPHATE 
&  LIME 


Fig.  46. 


Diagram  Showing  the  Relation  between  the  Water-supply  and  the 
Typhoid  Fever  Death-rate  in  Lorain,  Ohio. 


sulphite  process,  the  typhoid  fever  death-rate  in  the  city 
rose;  but  recently  with  somewhat  more  careful  operation 
the  rate   has  fallen,  even  though    the  filter    has   been 


INFLUENCE  OF   PUBLIC  WATER-SUPPLIES.     263 

much  overworked  on  account  of  the  rapidly  increasing 
population. 

These  records  are  interesting  as  showing  the  effect  of 
faulty  operation  of  a  filter  plant  on  the  health  of  the  city. 
Lorain  has  recently  constructed  a  new  filter. 

Stream  Pollution  and  Typhoid  Fever. 

Typhoid  fever  often  sweeps  down  a  river  valley  as  a 
sort  of  wave.  A  number  of  instances  of  this  have  been 
already  cited.  On  the  Penobscot  River  the  Millinocket 
epidemic  so  infected  the  water  that  the  fever  broke  out 
at  Oldtown,  Brewer  and  Bangor.  On  the  Kennebec 
River  the  Waterville  epidemic  caused  several  hundred 
cases  in  Augusta  and  Richmond.  On  the  Merrimac 
River  the  disease  spread  from  Lowell  to  Lawrence  and 
Newburyport. 

Perhaps  one  of  the  most  striking  examples  of  the 
infection  of  a  river  valley  is  that  of  the  Hudson  River 
and  its  tributaries.  Good  water-power  sites  caused  the 
early  development  of  many  large  communities  along  these 
streams,  and  naturally  these  cities  and  towns  emptied 
their  sewage  into  the  rivers  as  the  most  convenient 
places  of  disposal.  Unfortunately,  some  of  the  com- 
munities lower  down  used  the  water  for  drinking  and 
without  filtration.  The  experience  of  Albany  has  been 
referred  to.  Typhoid  fever  raged  there  until  the  filter  was 
built.  It  will  be  interesting  to  note  the  death-rates  of 
some  of  the  other  cities  along  these  streams.  Fig.  47 
shows  how  the  epidemic  which  occurred  in  Schenectady 
in  1890-92  affected  the  cities  dowm  the  valley.  At 
that    time    Albany    had    no  filter  plant,  and   those   at 


400 


U 


u 


Q   2 


u     0 


Pi   rt 


1890 


1894 


264 


INFLUENCE  OF  PUBLIC  WATER-SUPPLIES.     265 

Hudson  and  Poughkeepsie  were  old  and  imperfect  in 
operation. 

A  study  of  the  records  of  the  New  York  State  Depart- 
ment of  Health  reveals  the  presence  of  an  exceptional 
amount  of  typhoid  fever  in  the  Hudson  Valley  region 
as  compared  with  other  regions.  In  general  the  death- 
rate  is  about  twice  as  high  as  that  for  the  entire  state. 
Many  other  river  valleys  are  likewise  overrun  with 
typhoid  fever,  —  the  Susquehanna  River,  the  Potomac 
River,  the  Ohio  River,  the  Mississippi  River,  etc. 

These  waves  of  typhoid  fever  which  pass  down  a  river 
valley  are,  of  course,  due  in  the  main  to  the  water  car- 
riage of  the  bacilli;  but  it  is  conceivable  that  there  may 
be  other  modes  of  transmission,  and  that  the  disease 
may  follow  the  general  trend  of  the  lines  of  travel,  just 
as  Asiatic  cholera  used  to  follow  the  oriental  caravans 
and  sweep  westward  from  Asia  across  the  continent  of 
Europe. 

In  seeking  to  prevent  this  spread  of  typhoid  fever  by 
rivers,  the  question  has  been  raised  in  a  number  of  places 
as  to  whether  it  is  better  to  purify  the  sewage  of  an  upper 
city  on  some  river  or  to  filter  the  water  of  a  lower  city. 
The  answer  is,  —  both  are  desirable  and  in  the  course 
of  time  both  are  destined  to  take  place.  But,  except 
in  a  few  instances,  both  are  not  now  needed.  It  is 
generally  much  cheaper  to  filter  the  water  below  than 
it  is  to  purify  the  sewage  above,  and  in  the  present 
state  of  the  art  it  is  also  more  efficient.  In  general, 
water  filtration  should  come  first.  Later,  when  the  load 
is  greater  than  the  filters  can  safely  bear,  works  for  the 
purification  of  the  sewage  should  be  installed,  or  else 


266  TYPHOID   FEVER. 

double  filtration  of  the  water  required.  What  is  best 
to  do  must  depend  upon  the  peculiar  circumstances  of 
each  case. 

The  direct  pollution  of  streams  by  mills  and  factories, 
so  located  that  fecal  matter  from  privies  and  water-clos- 
ets finds  direct  access  to  the  water,  is  a  particularly  dan- 
gerous form  of  contamination.  Several  epidemics  have 
arisen  from  such  cases,  as  for  example,  in  Lowell, 
Mass.,  and,  probably,  Watertown,  N.Y. 

Stream  pollution  has  another  side,  however,  namely, 
the  nuisances  to  which  the  disposal  of  sewage  gives  rise, 
and  these,  taken  in  connection  with  sanitary  considera- 
tions, are  going  to  result  in  the  establishment  of  many 
sewage  purification  plants  along  our  lakes  and  streams. 
Unquestionably  many  American  streams  are  being 
rapidly  spoiled,  and  before  it  is  too  late  much  energetic 
work  ought  to  be  done  to  prevent  this.  Stream  pollu- 
tion is  the  result  of  the  prosperity  of  our  cities,  but  if  by 
increasing  our  capital  in  the  form  of  mills  and  factories, 
we  decrease  it  in  the  form  of  natural  water  resources,  we 
are  not,  as  a  nation,  growing  rich  as  rapidly  as  we  think. 
The  writer  is  not  unaware  that  in  some  cases  water- 
supplies  have  been  taken  from  contaminated  sources  and 
used  for  many  years  with  no  apparent  serious  effect  on  the 
public  health  ;  and  he  is  not  unaware  that  some  engi- 
neers, and  even  some  physicians,  still  hold  to  the  old 
theory  that  running  water  purifies  itself  to  an  extent  that 
is  sufficient  for  practical  purposes.  He  has  not  failed  to 
consider  this  negative  evidence,  but  in  spite  of  it  he  holds, 
as  do  the  majority  of  sanitary  engineers  to-day,  that  water 
once   contaminated  is  always  dangerous  until  purified. 


CHAPTER  XI. 

THE  EFFECT  OF   MILK-SUPPLIES  ON  THE  TYPHOID 
FEVER   DEATH-RATES   OF   CITIES. 

This  chapter  must  be  short,  as  the  data  for  a  fair 
discussion  of  the  subject  have  not  yet  been  collected. 
It  is  one  of  the  problems  for  the  sanitarians  of  to-day 
to  work  out.  Up  to  the  present  time  there  are  very 
few,  if  any,  American  cities  provided  with  a  thor- 
oughly safe  and  wholesome  milk-supply.  Pasteuriza- 
tion or  sterilization  have  not  become  general,  although 
the  public  conscience  is  becoming  awakened  to  the  need 
of  some  such  general  treatment. 

The  relative  merits  of  the  inspection  of  the  milk  farms 
and  the  general  pasteurization  of  the  milk-supply  is 
being  much  discussed  nowadays.  It  is  argued,  on  the 
one  hand,  that  pasteurization  is  inefficient  as  ordinarily 
carried  on,  that  it  renders  milk  less  easily  digested  and 
that,  by  destroying  certain  natural  germicidal  properties 
of  the  milk  by  heating,  it  reduces  its  keeping  qualities 
and  renders  a  subsequent  infection  more  dangerous;  and 
it  is  argued,  on  the  other  hand,  that  inspection  cannot 
guarantee  against  infection,  that  pasteurization  can  be 
made  efficient,  and  that  the  germs  of  typhoid  and  the 
non-sporing  bacteria,  at  least,  will  not  subsequently 
develop    after   pasteurization.     It    is    not    necessary    to 

267 


268  TYPHOID    FEVER. 

recite  here  all  the  arguments,  scientific  and  commercial, 
that  have  been  made,  for  the  subject  is  one  upon  which 
the  requisite  data  have  not  all  been  obtained.  There 
are  many  aspects  of  the  milk  question.  Typhoid  fever  is 
not  the  only  disease  involved.  Milk  may  be  the  means 
of  transmitting  scarlet  fever,  diphtheria,  tuberculosis, 
and  other  diseases.  Dirty  milk,  even  when  not  directly 
infected  with  specific  bacteria  from  some  previous  case 
of  disease,  may  produce  serious  intestinal  disorders  in 
bottle-fed  infants,  —  and  this  may  be  due  simply  to  a 
disregard  of  ordinary  cleanliness  in  the  handling  of  the 
milk  and  in  the  treatment  of  the  milk  bottles.  It  may 
be  too  early  to  prophesy,  but  in  the  author's  view  the 
solution  of  the  milk  question  will  finally  be  that  in 
srnall  communities,  where  there  are  personal  relations 
between  producer  and  consumer,  pasteurization  will 
not  be  needed,  but  that  in  large  communities,  where 
there  can  be  no  such  personal  relation,  pasteurization 
or  its  equivalent  will  be  looked  upon  as  the  only  safe- 
guard, and  will  be  made  compulsory  by  law.  But  even 
with  pasteurization  required,  the  inspection  of  the  farms 
will  still  be  needed.  As  in  the  case  of  water-supplies 
future  sanitarians  will  demand  a  clean  watershed  and 
then  filtration,  so  in  the  case  of  milk-supplies,  they  will 
insist  upon  clean  farms  and  pasteurization. 

The  advantages  of  pasteurization  are  slowly,  but 
surely,  being  manifested  by  experience.  Some  interest- 
ing examples  are  certain  cities  of  England  and  Scotland. 

The  diagram  (Fig.  48)  shows  that  in  Glasgow  there 
has  been  a  marked  reduction  in  typhoid  fever  during 
the  last  three  years.     This  cannot  be  accounted  for  by 


EFFECT  OF  MILK-SUPPLIES. 


269 


any  change  in  the  water-supply,  for  there  has  been  no 
change,  and  the  supply  is  taken  from  Loch  Katrine  and 


NOT  PASTEURIZED 


PASTEURIZED  IN  PART 


00  CT> 


Fig.  48. 


is  considered  to  be  of  excellent  quality.     About  three  or 
four  years  ago,  however,  they  began  a  practice  of  pas- 


2/0  TYPHOID    FEVEk. 

teurizing  much  of  the  milk  sold  in  the  public  shops,  and 
this  in  a  great  measure  is  thought  to  account  for  the 
decrease,  although  it  cannot  be  considered  as  the  only- 
cause. 

During  the  last  three  or  four  years  there  has  been 
a  decrease  in  the  amount  of  enteric  fever  in  Liverpool, 
although  at  no  time  during  the  last  ten  years  has  the 
rate  been  excessive.  The  decrease  is  probably  due  in 
part  to  improvements  which  have  been  made  on  the 
water-supply  watershed  and  to  greater  care  regarding  the 
use  of  oysters,  but  very  largely  to  the  increased  use 
of  pasteurized  milk.  The  improvements  in  the  water- 
shed have  consisted  of  the  purchase  and  reforesting 
of  large  areas,  and  the  improvement  of  the  sanitary 
conditions  on  the  farms  purchased.  The  water-supply 
is  filtered.  There  are  now  six  depots  for  the  sale  of 
steriHzed  and  modified  milk.  These  were  established 
in  1 901,  and  a  study  of  the  typhoid  statistics  of  the  city 
shows  that  the  decrease  in  the  death-rate  began  after 
1902.  During  the  last  three  years  the  general  death- 
rate  among  the  infants  supplied  from  these  depots  was 
about  96  per  1000  as  against  171  per  1000  for  the 
entire  city. 

Another  instance  of  the  benefits  of  pasteurization  is 
that  of  a  certain  milkman  in  Washington,  D.C.,  referred 
to  in  the  report  on  the  Origin  and  Prevalence  of  Typhoid 
Fever  in  the  District  of  Columbia  in  1906.  This  dealer 
sterilized  all  of  his  milk  bottles  and  pasteurized  all  of 
his  milk,  and  it  was  noticed  that  of  the  large  dealers  he 
had  the  smallest  number  of  typhoid  fever  cases  among 
his  customers  in  proportion  to  the  milk  sold.     A  com- 


EFFECT  OF  MILK-SUPPLIES. 


271 


parison  of  his  record  with  that  of  the  other  milk  dealers 
in  the  city  who  did  not  sell  pasteurized  milk  is  shown  by 
the  following  figures: 


Dairy. 

Gallons  of  Milk  Sold 
During  July,  August, 
September  and  Octo- 
ber, 1906. 

Number  of  Cases  of 
Typhoid  Fever  Dur- 
ing July,  August, 
September  and 
October,  1906. 

Number  of  Cases  of 

Typhoid  Fever  per 

100,000  Gallons  of 

Milk  Sold. 

A. 

35-995 

41 

II3-9 

B. 

102,867 

54 

52-S 

C. 

62,903 

23 

36.6 

D. 

5i>ii5 

18 

35-2 

E. 

71-350 

25 

3S-0 

F. 

71,690 

17 

23-7 

G. 

31-984 

7 

22.2 

H. 

77,098 

17 

22.0 

I. 

134,911 

29 

21-5 

J- 

27,247 

5 

18.4 

K. 

142,986 

26 

18.2 

L. 

43,800 

8 

18.2     • 

M. 

119,889 

20 

16.6 

N. 

29,247 

4 

137 

0. 

39,286 

5 

12.7 

P. 

44,496  Pasteurized 

3 

6.7 

Q- 

31.542' 

2 

6.3 

Then  there  is  the  general  experience  of  Germany 
and  other  countries  where  the  habit  of  boiling  the  milk 
before  using  is  widespread.  In  such  countries  the 
typhoid  rates  have  been  proverbially  low.  In  America 
sanitarians  have  been  inclined  to  regard  death-rates  of 
15  to  20  per  100,000  as  satisfactory  for  cities  having  good 
water-supplies,  —  but  these  rates  are  twice  as  high  as 
in  the  milk-boiling  countries. 

Next  in  importance  to  water  are  the  improvements 
needed   :n    the    milk-supplies,  —  cleaner  farms,    better 

^  Pasteurization  not  reported. 


2/2  TYPHOID    FEVER. 

methods  of  distribution,  and  general  pasteurization  for 
all  large  cities.  Progress  in  this  direction  thus  far  has 
been  small,  but  it  is  coming,  nevertheless,  and  coming 
speedily.  The  additional  value  of  good  milk  is  being 
recognized  by  its  advance  in  price.  Certified  milk 
commands  a  premium,  and  even  the  price  of  ordinary 
milk  is  increasing.  How  far  these  additional  charges 
are  justified  by  increased  cost  cannot  be  said,  but  the 
additional  charges  are  an  indication  that  the  public  is 
demanding  a  better  and  a  safer  quality  of  milk  than  it 
has  been  getting. 

Those  interested  in  the  subject  of  milk  should  con- 
sult the  very  elaborate  report  issued  by  the  Marine 
Hospital  Service  on  "  Milk  and  its  Relation  to  the 
Public  Health."  ^  This  is  an  exhaustive  treatise,  by 
various  authors,  on  all  phases  of  the  milk  problem.  It 
contains  various  data  for  several  hundred  epidemics  of 
typhoid  fever  caused  by  infected  milk. 

'  Hygienic  Laboratory  Bulletin,  No.  41. 


CHAPTER  XII. 

THE  FINANCIAL  ASPECT. 

However  much  we  may  dislike  to  measure  human  life 
in  gold  dollars,  or  to  balance  human  suffering  against 
the  coin  of  the  realm,  we  cannot  but  admit  that  the 
financial  aspect  of  typhoid  fever  is  an  important  matter 
in  the  United  States,  and  that  it  has  a  ver\'  practical 
bearing  on  the  whole  problem.  Hence,  we  are  com- 
pelled to  devote  some  attention  to  the  argumentum  ad 
crumenam. 

Having  discussed  this  subject  at  some  length  in  his 
book  on  "  The  Value  of  Pure  Water,"  the  author  takes 
the  liberty  of  presenting  here  in  an  abridged  form  some 
of  the  conclusions  there  reached. 

Financial  Value  of  Human  Life.  The  financial  value 
of  a  human  life  is  generally  taken  for  purposes  of  calcu- 
lation as  $5,000,  but  according  to  Marshall  O.  Leighton  it 
varies  at  different  ages  from  $1,000  to  87,000,  as  shown 
by  the  table  on  page  274. 

It  so  happens  that  persons  are  most  exposed  to  typhoid 
fever  near  the  age  when  their  life-value  is  considered 
greatest. 

By  combining  the  life-value  at  different  ages  with 
the  age  distribution  of  persons  dying  of  typhoid  fever, 
the    resulting    average    value    of    persons    dying    from 

273 


274 


TYPHOID    FEVER. 


typhoid  fever  is  found  to  be 
to  the  figure  ordinarily  used. 


t,634,  which  is  very  close 


Age. 


Estimated 

Value  of 

Human  Life. 


Per  cent  of 

Deaths  from 

Typhoid 

Fever. 


Product  of 

Columns  2 

and  3. 


o-  5  years 

5-10 
10-15 
15-20 
20-25 
25-30 
30-35 
35-40 
40-45 
45-50 
50-55 
55-60 
60-65 
65-70 
70- 

Total 


$1,500 
2,300 
2,500 
3,000 
5,000 
7>5oo 
7,000 
6,000 
5.500 
5,000 
4,500 
4,500 
2,000 
1,000 
1,000 


5-0 

5-9 
7.2 

131 

16.  7 

13.2 

9.9 


$7,510 

i3>57o 
18,000 

39,300 

83,500 

99,100 

69,300 

48,000 

30,900 

20,000 

15,000 

11,700 

4,200 

1,500 

1,900 


$463,480 


Average  value  of  life  of  persons  dying  from  typhoid  fever,  $4,634. 


The  percentage  fatality  of  typhoid  fever  patients  is 
sometimes  stated  as  lo  per  cent,  that  is,  ten  cases  for 
every  death;  but  it  has  been  shown  elsewhere  that  12 
to  15  cases  for  each  death  would  be  nearer  the  truth. 
The  expense  of  medical  treatment,  nursing,  and  medicine, 
the  loss  of  wages  for  a  month  or  more,  together  with 
other  attending  expenses  and  inconveniences,  would 
doubtless  aggregate  at  least  $100  per  case,  or  $1,000  for 
the  ID  cases  corresponding  to  one  death.  If  the  estimate 
of  $100  is  considered  too  large,  it  may  be  answered  that 
any  excess  is  more  than  offset  by  the  fact  that  there  are 


THE  FINANCIAL  ASPECT.  275 

more  often  from  12  to  15  cases  for  each  death  than  there 
are  10.  It  may  be  fairly  assumed,  therefore,  that  $6,000 
is  a  very  moderate  estimate  of  the  financial  loss  to  a 
community  from  typhoid  fever  for  each  death  from  that 
disease. 

What  Typhoid  Fever  Costs  the  Country.  The  United 
States  Census  of  1900  stated  that  during  that  year  there 
were  35,379  reported  deaths  from  typhoid  fever  in  the 
United  States.  If  it  be  assumed  that  each  one  of  these 
represents  a  loss  of  capital  to  the  community  of  $6,000, 
the  total  amount  is  found  to  be  $212,000,000.  Of  the 
35,379  deaths  from  this  disease,  probably  three-quarters 
of  them  at  least  could  have  been  prevented ;  that  is,  the 
needless  loss  of  vital  capital  was  about  $150,000,000. 
This  was  for  only  one  year,  and  the  same  thing  is  con- 
tinually going  on,  although,  thanks  to  sanitary  science, 
to  a  lessening  extent. 

Such  figures  as  these  are  often  set  forth  with  some 
variations  to  show  the  effect  of  typhoid  fever.  They 
have  but  little  definite  value,  but,  taken  in  connection 
with  the  effects  and  cost  of  water  filtration  and  other 
sanitary  measures,  they  serve  to  show  the  enormous 
saving  that  it  is  possible  to  bring  about. 

To  filter  all  the  water-supplies  of  the  important  cities 
of  the  country,  and  to  institute  such  sanitary  reforms 
that  three-quarters  of  the  deaths  from  typhoid  fever 
would  be  prevented,  would  cost  only  a  small  part 
of  the  loss  from  this  disease.  As  an  illustration  of 
what  can  be  done,  let  us  consider  the  effects  of  water 
filtration. 


2/6 


TYPHOID    FEVER. 


EFFECT  OF  FILTRATION  ON  DEATH-RATES  AT  ALBANY, 
N.Y.,  AND  A  COMPARISON  WITH  TROY,  N.Y.,  WHERE 
THE   WATER   WAS   NOT   FILTERED, 


ALBANY. 


Death-Rates  per  100,000. 

1894-98, 
Before  Fil- 
tration at 
Albany. 

1900—04, 
After  Fil- 
tration at 
Albany. 

Difference. 

Per  Cent 
Reduction 
of  Death- 
Rates. 

Typhoid  fever 

Diarrheal  diseases    .... 

Children  under  5  years  .    . 

Total  deaths.    .    .    . 

104 

125 

606 

2,264 

26 

53 

309 

1,868 

78 

72 

297 

378 

75 
57 
49 
17 

TROY. 


Typhoid  fever 

Diarrheal  diseases    .    .    . 

Children  under  5  years  . 

Total  deaths     .    . 


57 

57 

0 

116 

102 

14 

531 

435 

96 

2,157 

2,028 

129 

Filtered    water   was   introduced   into  Albany  in  li 
supply  of  Troy  has  remained  practically  unchanged. 


The  water- 


Effect  of  Filtration.  Typhoid  fever  is  by  no  means 
the  only  disease  transmitted  by  contaminated  water. 
Dysentery  and  various  other  diarrheal  diseases  precede 
it  or  follow  in  its  train,  and  in  most  instances  these  are 
probably  due  to  the  same  general  sources  of  contami- 


THE   FINANCIAL  ASPECT.  277 

nation  as  those  which  caused  the  typhoid  fever,  although, 
of  course,  to  different  specific  infections.  The  reduction 
of  the  typhoid  fever  death-rate  following  the  substitu- 
tion of  a  pure  water  for  a  contaminated  water  is  often 
accompanied  by  a  drop  in  the  death-rate  from  other 
diseases.  Thus,  if  the  five  years  before  and  after  filtered 
water  was  introduced  into  Albany,  N.Y.,  are  compared, 
it  will  be  seen  that  the  reductions  in  deaths  from  general 
diarrheal  diseases  and  the  deaths  of  children  under  five 
years  of  age  were  much  greater  than  in  the  case  of  typhoid 
fever.  There  was  also  a  reduction  in  malaria,  but  this 
probably  represents  faulty  diagnosis  of  typhoid  fever 
cases  before  the  introduction  of  the  filters,  rather  than  a 
real  reduction  of  malaria.  That  the  reduction  of  infant 
mortality  and  deaths  from  diarrheal  diseases  was  not 
due  to  other  conditions  seems  probable  from  the  fact  that 
in  the  neighboring  city  of  Troy,  where  the  water-supply 
was  not  changed,  there  was  no  such  diminution  during 
the  same  period. 

Hazen,  in  his  paper  on  "Purification  of  Water  in 
America, "  read  at  the  International  Engineering  Congress 
at  St.  Louis,  called  attention  to  this  same  fact,  that  after 
the  change  from  an  impure  to  a  pure  supply  of  water, 
the  general  death-rate  of  certain  communities  investi- 
gated fell  by  an  amount  considerably  greater  than  that 
resulting  from  typhoid  fever  alone  —  indicating  either 
that  certain  other  infectious  diseases  were  reduced  more 
than  typhoid  fever,  or  that  the  general  health  tone  of  the 
community  had  been  improved.  Thus,  for  five  cities 
where  the  water-supply  had  been  radically  improved  he 
found : 


2/8  TYPHOID    FEVER. 

Per  100,000 

Reduction  in  total  death-rate  in  five  cities  with  the  introduction  of  a 

pure  water-supply        440 

Normal  reduction  due  to  general  improved  sanitary  conditions, 
computed  from  average  of  cities  similarly  situated,  but  with  no 
radical  change  in  water-supply 137 

Difference,  being  decrease  in  death-rate  attributable  to  change  in 

water-supply .      303 

Of  this,  the  reduction  in  deaths  from  typhoid  fever  was 71 

Leaving  deaths  from  other  causes  attributable  to  change  in  water- 
supply    232 

From  these  facts  it  is  evident  that  to  place  the  finan- 
cial loss  to  a  community  as  $6,000  for  each  death  from 
typhoid  fever  due  to  the  public  water-supply  is  to  use  too 
low  a  figure.  It  probably  ought  to  be  several  times  as 
high;  but  recognizing  the  lower  financial  value  placed 
on  the  lives  of  infants,  and  the  less  serious  character  of 
the  other  diseases,  and  wishing  to  be  as  conservative  as 
possible,  for  the  reason  that  typhoid  fever  is  not  entirely 
a  water-borne  disease,  $10,000  per  typhoid  death  has 
been  used  in  the  calculation  which  follows. 

Since  typhoid  fever  is  a  disease  which  may  be  trans- 
mitted in  other  way  than  by  water  it  is  necessary  to  allow 
a  certain  death-rate  for  these  other  causes,  for  even  in  a 
city  where  the  water-supply  is  perfect  there  may  still  be 
some  typhoid  fever.  To  establish  a  figure,  this  typhoid 
fever  of  miscellaneous  origin  is  a  difficult  matter,  but  for 
purposes  of  calculation  we  may  assume  it  to  be  determined 
and  represent  it  by  the  letter  N.  It  is  used  as  a  synonym 
for  the  "residual"  typhoid  already  referred  to,  and  is, 
of  course,  variable  and  subject  to  local  conditions. 


THE    FINANCIAL  ASPECT.  279 

If  we  assume  that  all  typhoid  fever  in  excess  of  TV  is 
due  to  the  water-supply,  and  if  we  assume  that  the  daily 
consumption  of  water  is  100  gallons  per  capita,  then 
letting  T  equal  the  typhoid  fever  death-rate  per  100,000  — 

{T  —  N)  10,000  =  loss  to  the  community  in  dollars 

for    365  X  100  X  100,000    gallons    of    water,  or    D  = 

(T  -  N)  1,000 

=  2.75    {T  —  N),  where  D  stands  for 

365 
the  loss  in  dollars  per  million  gallons  of  water  used. 

Suppose  the  average  typhoid  fever  death-rate  for  a 
community  which  has  a  somewhat  polluted  water-supply 
has  averaged  43  per  100,000  for  a  period  of  five  years, 
and  suppose  that  for  this  place  the  value  of  N  is  estimated 
as  15,  then  — 

D  =  2.75  (43  —  15)  =  $76.72  if  the  per  capita  con- 
sumption is  100  gallons.  If  the  consumption  per  capita 
is  115  gallons,  D  would  be  \^^  of  $76.72,  or  $66.71;  if 
it  were  63  gallons  per  capita,  then  D  would  equal  -^3^- 
of  $76.72,  or  $121.77. 

The  following  examples  illustrate  to  what  extent  the 
sanitary  value  of  a  polluted  public  water-supply  is  in- 
creased by  an  efficient  system  of  filtration: 

Lawrence,  Mass.  — 

Water-supply,  Merrimac  River,  filtered  by  a  slow  sand  filter. 

Population,  70,000. 

Water  consumption,  40  gallons  per  capita  daily. 

Before  filtration  the  typhoid  fever  death-rate  was  121  per  100,000; 
since  then  it  has  been  26. 

Before  filtration  I?  =  2.  75  (121  —  20)    X  ^^%°  =  $693. 

After  filtration  D  =.  2.75  (26  —  20)  X  ^^jV"  =  $4i- 

Increase  in  sanitary  value  =  $693  —  $41  =  $652  per  million  gal- 
lons, or  $665,000  per  year,  or  $9.50  per  year  per  capita. 


28o  TYPHOID    FEVER. 

Albany,  N.Y.  — 

Water-supply,  Hudson  River,  filtered  by  sand  filter. 

Population,  95,000. 

Water  consumption,  165  gallons  per  capita  daily. 

Before  filtration  the  typhoid  fever  death-rate  was  104  per  100,000; 

since  then  it  has  been  26. 
Before  filtration  D  =  2.75  (104  -  20)  X  iff  =  $140. 
After  filtration  Z)  =  2.75  (26  -  20)  X  iU  =  ^10. 
Increase    in    sanitary    value     =  $140  —  $10  =  $130    per    million 

gallons,  or  $450,000  per  year,  or  $4.75  per  capita  per  year. 

Binghamton,  N.Y.  — 

Water-supply,  Susquehanna  River,  filtered  by  a  mechanical  filter. 

Population,  42,000  (approximately). 

Water  consumption,  160  gallons  per  capita  daily. 

Typhoid  fever  death-rate  before  filtration,  49;    after  filtration,  ii 

per  100,000. 
Before  filtration  Z?  =  2 .  75  (49  -  11)  X  M£-  =  $65. 
After  filtration  D  =  2.75  (11  -  11)  X  {U  =  o. 
'  Increase  in  sanitary  value  =  $65.00  per  million  gallons,  or  $160,000 

per  year,  or  $3 .  80  per  capita  per  year. 

Watertown,  N.Y.  — 

Water-supply,  Black  River  filtered  by  Mechanical  filter. 

Population,  25,500  (approximately). 

Water  consumption,  160  gallons  per  capita  daily. 

Typhoid  fever  death-rate  before  filtration,  68  per  100,000  ;  after 

filtration,  19.5. 
Before  filtration  Z?  =  2.75  (68  -  20)  X  ^U  =  $82.50. 
After  filtration  Z)  =  2 .  75  (20  -  20)  X  -\%°-  =  o. 
Increase  in  sanitary  value  $82.50  per  million  gallons,  or  $120,000 
per  year,  or  $4.75  per  capita  per  year. 

Illustrations  like  the  above  might  be  multiplied,  but 
the  four  cases  selected  are  sufficient  to  illustrate  the 
general  fact.  It  is  easily  seen  from  them  that  the  filtra- 
tion of  a  polluted  public  water-supply  increases  to  a  very 
great  extent  the  vital  assets  of  a  community,  and  the 
increase  in  most  cases  is  many  times  greater  than  the  cost 


THE  FINANCIAL  ASPECT.  28 1 

of  constructing  and  operating  the  works.  Money  paid  to 
the  doctor,  the  apothecary,  and  the  undertaker  is  not,  in 
one  sense,  a  loss  to  a  community,  as  it  is  merely  a  trans- 
ference of  money  from  one  man's  pocket  to  another's, 
but  in  the  broader  sense  any  loss  of  productive  capacity 
or  any  unnecessary  expenditure  is  a  loss.  Deaths  from 
typhoid  fever  and  from  other  diseases,  however,  represent 
a  very  material  loss  of  the  productive  capacity  of  a 
community,  and  consequently  a  decrease  in  what  may 
be  termed  the  "vital  assets."  In  the  case  of  the  city  of 
Albany,  for  instance,  the  increased  worth  of  the  water 
to  the  city,  because  of  its  efficient  filtration,  amounts 
to  $475,000  per  year,  of  which  at  least  $350,000  may  be 
considered  as  a  real  increase  in  the  vital  assets  of  the  city. 
If  in  the  formula  D  =  $2.75  {T  -  N)  we  let  T  -  AT 
=  I,  then  D  =  $2.75;  that  is,  a  decrease  in  the  typhoid 
fever  death-rate  of  i  per  100,000  causes  an  increase  in 
the  vital  assets  of  the  city  of  $2.75  for  each  million  gal- 
lons of  the  public  water-supply  (assuming  this  to  be  100 
gallons  per  capita),  or  $0.10  per  capita  per  year  for  each 
unit  reduction  of  the  typhoid  fever  death-rate  per  100,- 
000.  In  other  words  the  decrease  in  the  typhoid  death- 
rate  per  100,000  divided  by  10  gives  the  increased  vital 
assets  of  the  community  in  dollars  per  capita  per  year. 
Thus  in  the  case  of  Albany,  above  given,  the  reduction 
in  the  typhoid  fever  death-rate  was  78  per  100,000.  On 
the  basis  of  10  cents  per  capita  per  unit  decrease,  this 
would  amount  to  $0.10  X  78  X  95,000  =  $741,000  per 
year,  assuming  a  per  capita  consumption  of  100  gallons 
daily,  or  $450,000  for  a  per  capita  consumption  of  165 
gallons  daily,  which  is  the  figure  stated  above. 


282  TYPHOID    FEVER. 

Looking  at  the  matter  in  another  way,  it  may  be  said 
that  the  purification  of  a  polluted  water  is  a  sort  of  life 
insurance  for  the  people,  the  value  of  which  is  equal  to 
ID  cents  per  capita  for  each  unit  decrease  in  the  typhoid 
fever  death-rate  per  100,000  which  it  brings  about. 
Such  a  sum  capitalized  represents  a  large  amount  of 
money.  In  Albany,  for  example,  where  the  typhoid 
fever  death-rate  has  been  reduced  78  per  100,000,  the 
annual  saving  of  life-value  would  be  $7.80  per  capita. 
Capitalized  on  the  basis  of  an  annual  life-insurance 
premium  of  $17  per  thousand,  this  would  represent  an 
insurance  policy  of  about  $460  per  year  for  each  inhabi- 
tant, or  $2,300  for  each  head  of  a  family. 

Effect  of  Contamination.  The  average  death-rate 
from  typhoid  fever  in  American  cities  which  have  more 
than  30,000  inhabitants  is  about  35  per  100,000.  Apply- 
ing formula  (i),  and  assuming  a  value  of  20  for  N,  then 

D  =  2.75  (35  -  20)  -  $41-25; 
that  is,  the  average  depreciation  value  of  the  water-sup- 
plies of  our  American  cities,  taken  as  a  whole,  is  $41.25 
per  million  gallons,  because  of  their  unsanitary  quality, 
or  about  $15,000  per  annum  for  each  million  gallons  a 
day  of  supply. 

The  above  figure  takes  into  account  both  good  and  bad 
supplies.  The  average  typhoid  fever  death-rate  in  those 
cities  which  have  reasonably  good  water-supplies  may  be 
taken  in  round  numbers  as  about  20,  while  in  those  cities 
which  have  supplies  more  or  less  contaminated  it  varies 
from  this  up  to  40  or  60.  In  some  of  the  worst  cases  it  is 
more  than  100  per  100,000.  In  Pittsburg,  for  example, 
the  typhoid  death-rate  for  several  years  has  averaged  120. 


THE  FINANCIAL  ASPECT. 


283 


Here,  according  to  formula  (i),  D  =  2.75  (120  —  20)  = 
$2 7 5  per  million  gallons.  This  is  figured,  however,  on 
a  per  capita  water  consumption  of  100  gallons  a  day. 
The  actual  consumption  is  about  250  gallons  per  capita 
per  day;  hence  D  should  be  taken  as  o-| ^  of  S275,  or  Siio 
per  millioji  gallons.  Each  million  gallons  of  polluted 
Allegheny  River  water  pumped  to  Pittsburg  has,  there- 
fore, reduced  the  vital  assets  of  the  community  by  Si  10. 
This,  for  a  population  of  350,000,  amounts  to  83,850.000 
per  year' — a  sum  enormously  greater  than  the  cost  of 
making  the  water  pure. 

Classifying  water  supplies  according  to  their  source, 
the  following  will  give  a  general  idea  as  to  the  amount  of 
depreciation  of  various  types  of  water  from  the  sanitary 
standpoint,  based  on  general  average  typhoid  fever 
death-rates : 

CH.\RACTER   OF   WATER  SUPPLY. 


Ground  waters,  except  in  cases  where  pollution  is 
excessive,  or  where  wells  are  driven  in  rock  or 
soil  abounding  in  fissures 

Filtered  waters  (assuming  modem  methods  of 
construction  and  operation) 

Surface  waters  — 

(a)  Ordinar}'  upland  waters,   with  insignificant 

contamination 

(b)  Slightly  contaminated  waters,  with  good  stor- 

age in  lakes  or  large  reser\'oirs 

(c)  River  waters,  slightly  contaminated,  little  or 

no  storage 

(d)  River  water=,  much  contaminated,  little  or  no 

storage      


Amount  of  Deprecia- 
tion in  Dollars  per 
Million  Gallons. 


$0.00 


50.00 


$0.00  to 
10.00  to 

25  .  GO  to   100.  00 

50.  00  to  200.  00 


284  TYPHOID    FEVER. 

Conclusion.  When  the  appalHng  ravages  of  typhoid 
fever  and  the  accompanying  great  financial  losses  are 
considered,  the  sums  spent  in  preventing  the  disease 
appear  beggarly.  This  is  true  all  along  the  line  from 
the  government  of  the  nation  to  that  of  the  smallest 
village. 

We  have  no  national  department  of  health.  We  ought 
to  have  such  a  department,  thoroughly  organized  and 
endowed  with  interstate  authority.  And  the  annual 
preventable  losses  from  typhoid  fever  alone  would  more 
than  support  such  a  department. 

Our  army  medical  corps  is  entirely  inadequate  to  the 
service,  and  organized  upon  a  wrong  principle.  The 
losses  from  typhoid  fever  in  the  Spanish  War  would 
have  paid  for  an  adequate  service  ten  times  over. 

Some  of  our  states  have  no  health  departments  worthy 
of  the  name,  and  in  some  there  is  not  even  an  attempt 
made  to  collect  the  vital  statistics.  Even  in  New  York 
state,  the  wealthiest  state  in  the  union,  the  appropria- 
tions for  the  department  of  health  are  ridiculously 
meager,  and  the  work  of  the  department  is  correspond- 
ingly insufficient  for  the  needs  of  the  community. 

Some  states,  on  the  other  hand,  have  too  many  sani- 
tary authorities,  and  water-supply  commissions  and 
sewerage  commissions  eat  up  appropriations  and  bring 
about  unhappy  conditions  of  divided  authority.  The 
states  provided  with  a  strong  central  board  of  health, 
well  organized  and  supported  are  the  states  in  which 
sanitary  reforms  have  made  greatest  progress. 

Many  cities  of  the  country  have  no  boards  of  health  or 
health  officers,  or,  if  they  have,  these  officers  are  such 


THE  FINANCIAL  ASPECT.  285 

only  in  name,  serving  without  pay,  and  knowing  little 
about  the  principles  of  sanitary  science. 

To  remedy  all  these  conditions  will  cost  money,  but  it 
will  pay.  It  will  pay  not  only  in  the  satisfaction  of 
having  clean  and  healthful  cities  to  live  in,  not  only  in 
the  joy  of  having  relieved  the  suffering  and  saved  the 
dying,  but  it  will  pay  in  hard  cash. 

Although  this  country  has  a  long  road  to  travel  before 
reaching  the  goal  of  perfect  sanitation,  yet  during  the 
last  decade  it  has  traveled  a  long  way  on  that  road. 
The  nation  should  be  proud  of  the  state  of  Massachusetts 
for  her  pioneer  work  in  sanitary  science;  it  should  be 
proud  of  such  an  example  as  the  city  of  Montclair,  N.J., 
jealously  guarding  the  health  of  her  citizens;  it  should 
be  proud  of  the  work  done  by  many  civic  organ- 
izations, many  an  editor  in  his  chair,  many  a  lawyer 
struggling  for  better  sanitary  laws,  many  a  family 
physician  doing  self-sacrificing  work  that  humanity  never 
dreams  of,  and  many  an  engineer  working  out  on  a  large 
scale  what  the  laboratory  student  has  learned  from  his 
test  tubes  and  his  microscope.  And  the  United  States 
should  be  proud  of  her  citizens  who,  in  ever  increasing 
numbers  and  in  many  states,  are  taking  an  intelligent 
interest  in  the  care  of  their  own  premises,  in  the  sani- 
tation of  their  city,  and  in  the  universally  important 
subjects  of  health  and  cleanliness. 


APPENDIX   I. 
THE    USE    OF   DISINFECTANTS. 

Definitions.  There  are  three  common  terms  that  are 
sometimes  used  interchangeably,  but  to  do  so  is  incorrect 
and  tends  to  a  confusion  of  ideas.  These  terms  are 
disinfectants,  a;itiseptics  and  deodorizers. 

Deodorizers  are  substances  that  destroy  or  cover  up 
odors,  without  necessarily  killing  germs  or  preventing 
their  growth.  Afitiseptic  substances  prevent  the  devel- 
opment of  bacteria,  without  necessarily  killing  them 
and  their  spores.  Disinfectants  actually  kill  the  germs. 
Disinfectants  and  antiseptics  differ  in  degree  rather  than 
in  kind.  Formaldehyde  used  in  minute  quantities  may 
act  as  an  antiseptic  agent;  used  in  larger  quantities  it 
may  act  as  a  disinfectant. 

Disinfectants  and  antiseptics  may  tend  to  reduce  odors 
by  arresting  or  preventing  decomposition,  but  this  is  not 
their  principal  function. 

Deodorizers  have  their  legitimate  uses,  but  they  are 
of  little  use  in  typhoid  fever.  When  there  is  danger 
from  disease  germs,  disinfectants  only  are  adequate  to 
the  task.  The  chief  objection  to  the  use  of  deodorizers 
as  a  class  is  that  they  tend  to  give  a  false  sense  of 
security. 

Methods  of  Disinfection.  The  methods  of  disinfection 
may  be  divided  into  four  groups: 

287 


288  TYPHOID  FEVER. 

1.  Burning  with  fire. 

2.  Killing  with  dry  heat. 

3.  Killing  with  hot  water  and  steam. 

4.  Poisoning  with  chemicals. 

These  will  be  discussed  only  in  so  far  as  they  relate 
to  typhoid  fever.  As  the  typhoid  bacillus  does  not  form 
spores  its  destruction  is  less  difhcult  than  it  otherwise 
would  be,  and  as  the  germ  is  not  thrown  off  into  the  air  to 
any  great  extent  the  problem  is  simpler  than  in  the  case 
of  diphtheria,  scarlet  fever,  smallpox  and  such  diseases. 

Fire.  It  goes  almost  without  saying  that  the  burning 
of  infected  articles  destroys  all  germ  hfe,  and  this  is  the 
safest  and  best  way  of  destroying  many  things  used 
around  a  typhoid  patient,  if  they  have  little  value.  Old 
bedding,  old  handkerchiefs  and  cloths  used  as  substitutes 
for  handkerchiefs  should  be  burned  in  the  stove.  Toilet 
paper  may  be  conveniently  disposed  of  in  the  same  way. 
Sometimes  the  stools  themselves  are  mixed  with  sawdust 
and  burned. 

Dry  Heat.  Articles  exposed  to  dry  heat  (temperatures 
of  150°  C.  or  more)  in  an  oven  or  "hot-air  sterilizer" 
for  an  hour  will  have  any  typhoid  germs  that  they  may 
contain  completely  destroyed,  so  far  as  they  lie  upon  the 
surface  of  the  articles.  Dry  heat  does  not  penetrate  to 
the  interior  of  packages  or  articles  piled  together  as  moist 
heat  does.  It  is  only  to  be  used  for  articles  that  might  be 
destroyed  by  moist  heat. 

Steam.  Steam  under  a  slight  pressure  is  useful  in 
hospital  work,  but  is  almost  never  available  elsewhere. 
A  few  minutes'  exposure  to  steam  which  has  a  pressure 
of  15  pounds  or  more  per  square  inch  is  sufficient  to  kill 


APPENDIX  I.  289 

typhoid  bacilli.  Steam  at  atmospheric  pressure,  that  is, 
the  steam  arising  from  boiling  water  in  an  open  dish, 
has  practically  the  same  effect  as  boiling  water. 

Boiling.  Typhoid  bacilli  are  killed  in  boiling  water 
or  in  streaming  steam  in  a  very  few  minutes,  but  if  the 
water  is  not  up  to  the  boiling  point  a  somewhat  longer 
time  is  required.  If  a  steam  sterilizer,  such  as  an 
"Arnold,"  is  used,  an  exposure  of  30  minutes  is  suf- 
ficient to  insure  safety,  but  if  articles  are  put  into  boiling 
water  it  is  better  to  let  them  remain  there  an  hour  or  even 
two  hours. 

Boiling  is  a  convenient  way  to  sterilize  the  knives, 
forks,  spoons  and  plates  used  by  the  patient,  and  also 
bed  linen,  underwear,  handkerchiefs,  etc.,  although  in 
the  case  of  these  fabrics  chemical  disinfectants  should 
first  be  used. 

Chemical  Disinfectants.  The  most  useful  chemical 
disinfectants  in  typhoid  fever  cases  are : 

1.  Ordinary  quicklime,  or  lime  freshly  slaked. 

2.  Chloride  of  lime.     (Bleaching  powder.) 

3.  Carbolic  acid. 

4.  Corrosive  sublimate,  or  bichloride  of  mercury. 

These  chemicals  are  all  poisons  and  are  listed  in  the 
order  of  their  poisonous  effect.  The  last-named  chemical 
is  exceedingly  poisonous  and  has  to  be  used  very  care- 
fully, and  all  the  more  so  because  it  has  no  odor  to  serve 
as  a  warning  as  in  the  case  of  carbolic  acid  and  chloride 
of  lime. 

It  should  be  remembered  also  that  corrosive  sub- 
limate acts  on  some  metals.     Solutions  of  it  should  not 


290  TYPHOID  FEVER. 

be  kept  in  metal  vessels,  but  in  wooden  pails,  or  tubs 
or  earthern  or  glass  jars.  It  should  not  be  used  for 
disinfecting  silverware,  and  one  should  be  careful  not  to 
wash  the  hands  in  it  without  first  removing  finger  rings. 
Solutions  of  chloride  of  lime,  carbolic  acid  and  corrosive 
sublimate  may  injure  the  lead  pipes  of  plumbing  fixtures 
if  used  in  large  quantities  without  flushing.  In  case 
these  solutions  are  put  into  a  water-closet,  let  the  water 
run  freely. 

The  relative  value  of  these  disinfecting  substances 
varies  with  the  uses  to  which  they  are  put.  Generally 
speaking,  carbolic  acid  and  corrosive  sublimate  are  best 
to  use  around  the  body  of  the  patient  and  in  the  sick 
room;  while  chloride  of  lime  and  quicklime  are  most 
serviceable  for  disinfecting  water-closets,  fecal  matter  in 
chamber  vessels,  and  cesspools,  and  for  general  out- 
of-doors  work.  Lime  is  especially  valuable  in  country 
practice,  while  the  other  disinfectants  are  more  con- 
venient for  use  in  city  apartments,  hospitals,  etc. 

Use  of  Lime.  Lime  is  comparatively  cheap,  costing 
from  less  than  half  a  cent  to  a  cent  a  pound,  according  to 
locality  and  quantity  purchased.  Old  Hme,  which  has 
become  "air-slaked"  is  of  no  use  whatever.  Lime 
freshly  burnt  is  known  as  "quicklime."  It  comes  in 
irregular  lumps  which  are  easily  broken.  The  dry  sub- 
stances may  be  used  for  disinfecting  fecal  matter.  In 
chamber  vessels  use  about  as  much  as  the  volume  of  the 
substance  to  be  disinfected.  In  water-closets  sprinkle 
freely  about  the  seat  and  floor  in  front  of  the  seat,  and 
after  each  evacuation  cover  the  feces  with  the  powdered 
lime  until  white.     In  cesspools  use  about  3  to  5  pounds 


APPENDIX  I.  291 

for  each  cubic  foot  of  contents.  This  might  amount  to 
a  barrel  of  lime  for  the  ordinary  sized  cesspool  of  a  one- 
family  house. 

Often  it  is  more  convenient  to  use  ''milk  of  lime." 
This  may  be  easily  made  by  slacking  the  lime,  that  is, 
by  mixing  it  carefully  with  something  less  than  its  own 
weight  of  water,  and  then  adding  to  the  hydrated  lime 
thus  made  about  eight  or  ten  times  its  weight  of  water. 
The  product  is  a  sort  of  white-wash,  which  can  be  used 
for  all  of  the  disinfecting  purposes  above  mentioned. 
It  ought  to  be  freshly  prepared,  but  will  keep  a  few  days 
in  a  closed  jar  with  the  air  excluded. 

Use  of  Chloride  of  Lime.  Chloride  of  lime  is  also 
comparatively  inexpensive.  It  can  be  purchased  in 
retail  lots  for  3  or  4  cents  a  pound,  and  in  quantities  for 
much  less.  It  is  sold  as  a  dry  powder  in  sealed  packages. 
Chemically,  chloride  of  lime  is  a  hypochlorite  of  calcium. 
It  owes  its  disinfecting  qualities  to  the  "available 
chlorine."  Some  grades  contain  more  of  this  than 
others,  and  are  therefore  worth  more.  Common  grades 
contain  20  to  30  per  cent  of  available  chlorine,  but 
some  grades  prepared  by  recently  introduced  electrolytic 
processes  contain  as  high  as  35  or  40  per  cent  of  available 
chlorine. 

Chloride  of  lime  may  be  used  dry  in  place  of  ordinary 
quicklime,  and  less  may  be  used,  but  quicMime  is 
cheaper,  less  odorous,  and  on  the  whole  better,  provided 
enough  of  it  is  used. 

To  prepare  a  disinfecting  solution  of  chloride  of  lime, 
dissolve  a  third  of  a  pound  (something  less  than  a  cupful) 
of  the  dry  substance  in  a  gallon  of  water. 


292  TYPHOID  FEVER. 

Use  about  one  quart  of  such  a  solution  to  disinfect 
each  fecal  discharge;  and  for  disinfecting  urine,  add 
volume  for  volume.  Allow  these  to  stand  for  at  least 
two  hours  in  order  to  give  time  for  thorough  disinfection. 
Break  up  any  lumps  of  fecal  matter  with  a  stick,  and 
immediately  burn  the  stick;  or  if  a  glass  rod  is  used, 
sterilize  the  rod. 

Prepare  the  solution  of  chloride  of  lime  each  time  when 
required,  or  at  least  once  each  day. 

Use  of  Carbolic  Acid.  The  best  grade  of  carbolic  acid 
is  purchased  as  a  soHd,  but  it  may  be  made  liquid  by 
adding  a  small  quantity  of  water  and  letting  the  bottle 
stand  in  boiling  water.  Crude  carbolic  acid  is  sold  as  a 
liquid.  The  purer  forms  are  not  needed  for  disinfecting 
purposes.  A  satisfactory  quality  of  carbolic  acid  can  be 
purchased  for  25  to  75  cents  per  gallon. 

A  5  per  cent  solution  of  carbolic  acid  is  that  generally 
used,  that  is,  about  tw^enty  times  as  much  water  as  acid, 
—  or  say  half  a  cupful  of  carbolic  acid  to  a  gallon  of 
water.  Such  a  solution  may  be  used  for  soaking  bed 
linen,  underwear,  handkerchiefs,  towels,  napkins,  etc., 
before  boiling.  Such  fabrics  should  soak  in  the  dis- 
infecting solution  for  upwards  of  an  hour.  Such  a 
solution  may  be  also  used  instead  of  chloride  of  lime  for 
disinfecting  fecal  discharges  and  urine. 

For  disinfecting  the  hands  or  for  bathing  the  patient, 
a  5  per  cent  solution  of  carbolic  acid  is  too  strong.  A 
2  per  cent  solution,  or  one  something  less  than  half  as 
strong,  is  preferable,  and,  as  the  acid  is  rather  harsh  to 
the  skin,  an  equal  volume  of  glycerine  should  be  added 
to  each  quart  of  solution. 


APPENDIX  I.  293 

It  is  not  so  important  to  have  these  solutions  freshly 
prepared  as  in  the  case  of  chloride  of  lime. 

Use  of  Corrosive  Sublimate.  Corrosive  sublimate  is 
purchased  as  a  white  crystalline  solid.  It  costs  at  retail 
from  75  cents  to  a  dollar  per  pound.  It  should 
not  be  used  without  dissolving  in  water.  Solutions  of 
different  strengths  are  used  for  different  purposes,  as 
foUows : 

Strong  Solution.  (1:500.)  Used  for  disinfecting 
fecal  matter,  urine,  etc. 

Corrosive  sublimate,  one  ounce  (about  a  tablespoonful). 

Hydrochloric  acid  (muriatic  acid),  one-half  ounce 
(about  tvv'o  tablespoonfuls). 

Water,  one  gallon. 

Permanganate  of  potash  (10  grains)  may  be  added  to 
give  a  color  to  the  solution,  in  order  that  it  may  not 
be  mistaken  for  water.  Common  washing  blueing  is 
equally  useful  for  this  purpose. 

Medium  Solution.  (1:1000.)  Used  for  disinfecting 
clothing,  bed  linen,  etc.,  and  often  used  for- fecal  matter. 
Also  used  for  disinfecting  the  hands,  for  disinfecting 
clinical  thermometers,  syringes,  glassware,  woodwork, 
door-knobs,  etc.  It  is  prepared  by  adding  one  teaspoon- 
ful  of  the  chemical  to  one  gallon  of  water.  In  this 
solution  no  hydrochloric  acid  need  be  added,  but  some- 
times a  quantity  of  ammonium  chloride,  equal  in  weight 
to  the  corrosive  sublimate,  is  used. 

Weak  Solutions.  Weaker  solutions  are  used  for  dis- 
infecting the  body  of  the  patient,  as  follows : 

(i :  3000. )  For  bathing  the  patient  after  each  stool,  for 
washing  the  scalp,  and  for  general  bathing. 


294  TYPHOID  FEVER. 

(i:8ooo.)  May  be  used  as  a  nasal  spray,  but  for 
cleansing  the  mouth,  Hps  and  nose,  solutions  of  boracic 
acid  are  to  be  preferred. 

In  using  corrosive  sublimate  it  should  be  remembered 
that  the  solutions  are  poisonous.  Especial  care  should  be 
taken  with  strong  solutions  if  one  has  cuts  on  the  hands. 

Corrosive  sublimate  is  somewhat  slower  in  action  than 
chloride  of  lime.  At  least  two  hours'  contact  should  be 
allowed. 

Use  of  Other  Chemicals.  Certain  other  chemicals 
may  be  used  for  disinfecting  purposes  in  place  of  those 
mentioned,  but  they  are  not  as  satisfactory  for  typhoid 
fever.     Among  these  may  be  mentioned : 

Formaldehyde  solutions,  i :  20. 

Copper  sulphate  (Blue  vitriol),  10  per  cent  solution. 

Iron  sulphate  (Copperas). 

Zinc  chloride,  10  per  cent  solution. 

Besides  these  there  are  many  other  substances,  such 
as  lysol,  that  are  useful  in  the  sick  room  and  about  the 
patient. 

Use  of  Urotropin.  Urotropin  is  a  valuable  urinary 
disinfectant.  It  should  be  used  only  on  prescription  by 
a  physician.  The  usual  dose  is  5  to  7  grains  three  times 
a  day,  preferably  after  meals,  continued  for  two  or  three 
days,  or  until  an  examination  of  the  urine  shows  that 
typhoid  bacilli  are  absent.  The  tablets  should  be 
dissolved  in  a  tumblerful  of  water  (temperature  less  than 
80°  F.). 

Fumigation.  Fumigation,  as  practised  in  the  case  of 
scarlet  fever,  measles,  etc.,  is  not  generally  considered 
necessary  in  typhoid    fever.     Nevertheless  on    account 


APPENDIX  I.  295 

of  its  contagiousness,  fumigation  is  a  wise  precaution, 
especially  in  those  instances  where  pulmonary  complica- 
tions supervene.  In  any  case,  however,  woodwork,  door- 
knobs, etc.,  should  be  washed  with  disinfectants  and  the 
bedding,  mattresses,  etc.,  thoroughly  cleansed. 


APPENDIX   II. 


HOUSE   FLIES. 


{Chiefly  from  a  paper  by  Dr.  L.  O.  Howard,  Chief  of  the  Bureau  of 

Entomology,  United  States  Department  of  Agriculture, 

Circular  No.  71.) 

Common  Species.  There  are  several  species  of  flies 
which  are  commonly  found  in  houses,  although  but  one 
of  these  should  properly  be  called  the  house  fly.  This  is 
the  Musca  domestica  (Fig.  49  a)  and  is  a  medium-sized, 
grayish  fly,  with  its  mouth  parts  spread  out  at  the  tip  for 
sucking  up  liquid  substances.  It  breeds  in  manure  and 
dooryard  filth  and  is  found  in  nearly  all  parts  of  the 
world.  On  account  of  the  conformation  of  its  mouth 
parts,  the  house  fly  cannot  bite,  yet  no  impression  is 
stronger  in  the  minds  of  most  people  than  that  this 
insect  does  occasionally  bite.  This  impression  is  due  to 
the  frequent  occurrence  in  houses  of  another  fly  {Stomoxys 
calcitrans),  which  is  called  the  stable  fly,  and  which, 
while  closely  resembling  the  house  fly,  differs  from'  it  in 
the  important  particular  that  its  mouth  parts  are  formed 
for  piercing  the  skin.  It  is  perhaps  second  in  point  of 
abundance  to  the  house  fly  in  most  portions  of  the 
Northeastern  States. 

A  third  species,  commonly  called  the  cluster  fly  (Pol- 
lenia  rudis),  is  a  very  frequent  visitant  of  houses,  par- 

296 


APPENDIX  II. 


297 


ticularly  in  the  spring  and  fall.  This  fly  is  somewhat 
larger  than  the  house  fly,  with  a  dark-colored,  smooth 
abdomen  and  a  sprinkling  of  yellowish  hairs.  It  is  not 
so  active  as  the  house  fly,  and  particularly,  in  the  fall,  is 
very  sluggish. 

A  fourth  species  is  another  stable  fly,  known  as  Mus- 
cina  stabulans,  a  form  which  almost  exactly  resembles 


Fig. 


49. 


Some  Common  Species  of  Flies  and  their  Larvae  and  Puparia. 
(After  L.  O.  Howard.) 


a.  Musca  dome stica,  the  common  house  fly. 

b.  Stomoxys  calcitrans,  the  stable  &y. 

c.  Phormia    terr(Enov(E,    the    small     blue 

bottle  fly. 


d.  Drosophila  ampelophia;  the  small  fruit 

fly. 

e,  /,  g.    Puparia. 
h,  i,  j.  Larvct. 


the  house  fly  in  general  appearance,  and  which  does  not 
bite  as  does  the  biting  stable  fly.  It  breeds  in  decaying 
vegetable  matter  and  in  excrement. 

Several  species  of  metallic,  greenish  or  bluish  flies  are 
also  occasionally  found  in  houses,  the  most  abundant  of 
which  is  the  so-called  blue-bottle   fly    {Calliphora  ery- 


298  TYPHOID  FEVER. 

throcephala).  This  insect  is  also  called  the  blow-fly  or 
meat-fly  and  breeds  in  decaying  animal  material.  A 
smaller  species,  which  may  be  called  the  small  blue- 
bottle fly,  is  Phormia  terroenovce;  and  a  third,  which  is 
green  in  color  and  about  the  size  of  the  large  blue-bottle, 
is  Lucilia  ccesar. 

There  is  still  another  species,  smaller  than  any  of  those 
so  far  mentioned,  which  is  known  to  entomologists  as 
Homalomyia  canicularis,  sometimes  called  the  small 
house  fly.  H.  canicularis  is  distinguished  from  the 
ordinary  house  fly  by  its  paler  and  more  pointed  body 
and  conical  shape.  The  male,  which  is  much  commoner 
than  the  female,  has  large  pale  patches  at  the  base  of  the 
abdomen,  which  are  translucent  when  the  fly  is  seen  on 
a^ window  pane. 

Still  another  fly,  and  this  one  is  still  smaller,  is  a  jet- 
black  species  known  as  the  window  fly  (Scenopinus 
jenestralis).  It  breeds  in  the  dust  under  carpets,  and 
its  larva  is  a  white,  very  slender,  almost  thread-like 
creature. 

In  the  autumn,  when  fruit  appears  on  the  sideboard, 
many  specimens  of  a  small  fruit  fly  {Drosophila  ampelo- 
phila)  make  their  appearance,  attracted  by  the  odor  of 
overripe  fruit. 

A  small,  slender  fly,  not  infrequently  seen  in  houses, 
especially  upon  window  panes,  is  Sepsis  violacea. 

All  of  these  species,  however,  are  greatly  dwarfed  in 
numbers  by  the  common  house  fly.  In  1900  collections 
were  made  of  the  flies  in  dining  rooms  in  different  parts 
of  the  country,  and  out  of  a  total  of  23,087  flies,  22,808 
were  Musca  domestica,   that   is,   98.8  per  cent  of  the 


APPENDIX  II.  299 

whole  number  captured.  The  remainder,  consisting  of 
1.2  per  cent  of  the  whole,  comprised  various  species, 
including  those  mentioned  above. 

Life  History  of  Flies.  Musca  domestica  commonly 
lays  its  eggs  upon  horse-manure.  This  substance  seems 
to  be  its  favorite  larval  food.  It  will  deposit  its  eggs  on 
cow  manure  and  will  also  breed  in  human  excrement,  and 
from  this  habit  it  becomes  very  dangerous  to  the  health  of 
human  beings,  carrying,  as  it  does,  the  germs  of  intestinal 
diseases  such  as  typhoid  fever  and  cholera  from  excreta 
to  food  supplies.  It  will  also  lay  its  eggs  upon  other 
decaying  vegetable  and  animal  material,  but  of  the  flies 
that  infest  dwelling  houses,  both  in  cities  and  on  farms, 
a  vast  proportion  comes  from  horse  manure.  In  hot 
weather  each  female  fly  lays  about  120  eggs,  which  hatch 
in  eight  hours,  the  larva  period  lasting  five  days  and  the 
pupa  five  days,  making  the  total  time  for  the  develop- 
ment of  the  generation  ten  days.  The  larvae  molt  twice, 
hence  there  are  three  distinct  larval  stages.  There  is 
thus  abundance  of  time  for  the  development  of  twelve  or 
thirteen  generations  in  the  climate  of  Washington  every 
summer.  The  periods  of  development  vary  with  the 
climate  and  with  the  season,  and  the  insect  hibernates 
in. the  puparium  condition  in  manure  or  at  the  surface  of 
the  ground  under  a  manure  heap.  It  also  hibernates  in 
houses  as  adult,  hiding  in  crevices. 

The  number  of  eggs  laid  by  an  individual  fly  is  so 
large,  that  the  enormous  numbers  in  which  the  insects 
occur  are  easily  accounted  for,  especially  when  we  con- 
sider the  abundance  and  universal  occurrence  of  appro- 
priate larval  food.     In  order  to  ascertain  the  numbers  in 


300  TYPHOID   FEVER. 

which  house-fly  larvae  occur  in  horse-manure  piles,  a 
quarter  of  a  pound  of  rather  well-infested  horse  manure 
was  taken  on  August  9,  and  in  it  were  counted  160  larvae 
and  146  puparia.  This  would  make  about  1200  house 
flies  to  the  pound  of  manure.  This,  however,  cannot  be 
taken  as  an  average,  since  no  larvae  are  found  in  perhaps 
the  greater  part  of  ordinary  horse-manure  piles.  Neither 
does  it  show  the  limit  of  what  can  be  found,  since 
about  200  puparia  were  found  in  less  than  i  cubic  inch  of 
manure  taken  from  a  spot  2  inches  below  the  surface 
of  the  pile  where  the  larvae  had  congregated  in  immense 
numbers. 

Movements  of  Flies.  Most  writers  claim  that  flies  do 
not  travel  far  from  the  locality  in  which  they  breed,  and 
little  is  known  as  to  what  distance  they  may  cover.  A 
single  stable  in  which  a  horse  is  kept  will  supply  house 
flies  for  an  extended  neighborhood.  Packard  thinks 
that  flies  can  scent  their  food  for  several  miles  and  may 
fly  20  or  30  miles  a  day  if  aided  by  winds.  Undoubtedly 
the  wind  plays  the  greatest  part  in  these  long  journeys 
of  flies,  and  there  seems  to  be  good  reason  to  believe  that 
most  flies  do  not  travel  far  from  the  vicinity  of  their 
breeding  places. 

Flies  and  Temperature.  Flies,  hke  all  insects,  are  most 
active  in  warm  weather.  On  cold  days,  especially  in  the 
autumn,  they  become  dormant  and  seek  sheltered  spots 
and  warm  places. 

In  order  to  determine  the  time  of  greatest  prevalence 
of  flies  in  New  York  City,  Mr.  D.  D.  Jackson  made  some 
interesting  observations  during  the  summer  of  1907,  in 
connection  with  a  report  to  the  Merchants'  Association. 


APPENDIX  II. 


301 


Many  cages  were  placed  in  different  parts  of  the  city, 
especially  along  the  water-front,  and  the  number  of  flies 
caught  at  each  place  was  counted  daily.  The  following 
figures  show  the  relative  prevalence  of  flies  at  one  of 
the  fly-cage  stations  in  Brooklyn. 


Date. 
Week  Ending  — 

Number  of  Flies 

Caught  During 

the  Week. 

Date. 
Week  Ending  — 

Number  of  Flies 

Caught  During 

the  Week. 

May    4 
II 
18 

25 

June    I 
8 

15 

22 

29 

July    6 

13 
20 
27 
Aug.   3 
10 

0 
0 

I 

3 

2 

8 

34 

75 

244 

921 

2696 

4165 

5727 
6224 
3926 

Aug.  17 

24 

31 

Sept.    7 

14 
21 
28 
Oct.    5 
12 

19 
26 

Nov.    2 

9 
16 

1165 
435 
99 
584 
888 
592 
182 

52 
47 
51 
32 
22 

7 
0 

Longevity  of  Flies.  The  longevity  of  flies  is  not  well 
known.  It  is  said  that  in  the  open  flies  may  live  a  sea- 
son, but  that  when  confined  in  jars  and  cages  they  often 
do  not  live  more  than  a  week  or  ten  days.  It  is  said 
also  that  flies  which  have  been  infected  with  certain 
disease  germs,  as  for  instance,  the  bacilK  of  anthrax  and 
tuberculosis,  succumb  more  quickly  than  others  not 
infected  kept  under  the  same  conditions. 

Means  of  Prevention.  The  problem  of  preventing  the 
house  fly  from  breeding  has  not  yet  been  solved.     Experi- 


302  TYPHOID   FEVER. 

ments  have  been  made  to  destroy  the  maggots  in  horse 
manure  by  the  use  of  kerosene,  crude  oil  and  chloride  of 
lime,  but  the  results  have  been  only  moderately  success- 
ful. And  at  the  present  time  the  best  method  of  avoiding 
the  fly  nuisance  appears  to  be  to  build  for  the  reception 
of  stable  manure  large  and  tightly  closed  pits,  well  venti- 
lated and  screened,  and  so  constructed  that  little  direct 
light  may  enter. 

Box  privies  are  a  nuisance  from  many  points  of  view 
and  are  dangerous  as  breeding  places  of  flies.  If  used 
at  all  they  should  be  conducted  on  the  earth-closet  prin- 
ciple, and  a  free  use  of  earth  and  powdered  lime  should 
be  made. 

Howard  says  that  "people  living  in  agricultural  com- 
munities will  probably  never  be  rid  of  the  pest,  but  in 
cities,  with  better  methods  of  disposal  of  garbage  and 
with  lessening  of  the  number  of  horses  and  stables 
consequent  upon  electric  street  railways  and  auto- 
mobiles, the  time  may  come  before  long  when  window 
screens  may  be  discarded.  Absolute  cleanliness  will 
always  result  in  a  diminution  of  the  numbers  of  the 
house  fly.  Horse  manure  should  be  gathered  and 
removed  promptly,  both  from  streets  and  from  stables; 
garbage  should  be  collected  frequently;  and  aU  forms  of 
excrement,  dead  animals  and  decaying  organic  matter 
of  every  description  promptly  taken  care  of." 


APPENDIX  ni. 

THE   ESTIMATION   OF    POPULATION. 

In  most  countries  a  general  census  is  made  once  in  ten 
years.  In  the  United  States  this  is  done  in  those  years 
which  are  divisible  by  ten,  that  is,  in  1880,  1890,  1900, 
etc.,  but  in  England  and  in  Canada  the  general  census 
is  taken  in  the  year  following  that,  that  is,  in  1891,  1901, 
etc.  In  many  of  the  states  an  intermediate  census  is 
taken  between  the  federal  censuses,  that  is,  in  1895, 
1905,  etc.  In  some  cities  censuses  are  taken  each  year, 
but  this  is  not  common,  although  an  aimual  record  is 
often  kept  of  the  number  of  school  children,  the  number 
of  voters,  the  number  of  houses,  etc.,  which  are  useful  in 
making  approximate  estimates  of  the  population. 

The  records  of  the  United  States  census  are  published 
by  the  Census  Bureau  of  the  Department  of  Commerce 
and  Labor,  and  various  bulletins  containing  them  can 
be  obtained  by  addressing  the  Director  of  the  Census 
Bureau,  Washington,  D.C. 

In  the  censal  years  the  exact  figures  given  by  the 
census  should  be  used  in  calculating  death-rates,  but  in 
the  years  between  censuses  it  is  necessary  to  estimate  the 
population.  There  are  various  ways  of  doing  this,  but 
the  one  most  commonly  used  is  based  on  the  assumption 
that  during  the  period  between  the  two  censuses  the 
population    increases    gradually,    so    that    the    estimate 

303 


304 


TYPHOID   FEVER. 


merely  involves   the   application  of  the  rule  of  three. 
Thus,  if  the  population  of  a  certain  town  was  10,000  in 


30,000 


30,000 


10,000 


<N 

is  II 

* 

/ 
/ 

CO 

• 

^^^ 

• 

y 

^^ 

J> 

^     ^ ' 

^^f^ 

^ 

w 

s 

>ip 

y 

CM 

h-  g 

.^ 

<^ 

^- 

\^'^ 

O) 

5  II 

t- 

.^ 

-J^ 

y- 

1- 

< 

^ 

^ 

;^^^ 

to 

t-  0 

CO 

< 

1880 


1885 


YEAR 
Fig.  50. 

Diagram  Showing  the  Arithmetical  and  Geometrical  Methods  of 
Estimating  Population. 

1880,  and  20,000  in  1890,  the  estimated  population  in 
1887  would  be  17,000. 

It  is  somewhat  more  difficult  to  correctly  estimate 
populations  in  the  years  following  a  census,  for,  in  this 
case,  there  is  but  one  fixed  population  to  reckon  from. 


APPENDIX  III.  305 

There  are-two  methods  commonly  used  for  estimating 
this  extra-censal  population,  —  the  arithmetical  and  the 
geometrical.  The  arithmetical  method,  which  is  the  one 
used  by  the  United  States  Census  Bureau,  assumes  that 
the  annual  increase  in  population  after  the  censal  year 
is  the  same  as  the  average  annual  increase  in  population 
during  the  period  between  the  last  two  censuses.  Thus, 
in  the  town  above  mentioned,  where  the  population  in 
1880  was  10,000  and  in  1890,  20,000,  the  estimated 
population  for  the  year  1892  would  be  22,000.  The 
geometrical  method  is  based  on  percentage  increase  and 
assumes  that  the  annual  percentage  increase  in  popu- 
lation in  the  years  after  the  census  is  the  same  as  the 
average  annual  increase  in  the  period  between  the  last 
two  censuses.  Thus,  in  the  town  referred  to,  the  popu- 
lation increased  100  per  cent  between  1880  and  1890, 
which  would  be  7.18  per  cent  per  year.  If  this  rate  were 
continued  after  1890,  then  the  population  in  1891  would 
be  21,000  and  in  1892,  23,000. 

The  formula  for  computing  population  in  this  way  is: 
P^  =  P^  (1  -r  r)  n  in  which  P^  is  the  population  desired, 
P^  the  population  given  by  the  last  census,  n  the  number 
of  years  since  the  last  census,  and  r  the  rate  of  increase. 
This  is  the  same  formula  as  that  for  compound  interest. 
In  any  estimate  of  this  sort  it  is  necessary  to  take  into 
account  local  conditions,  as  these  may  be  such  as  to  make 
the  application  of  either  formula  untrustworthy.  Often 
the  data  showing  the  increase  in  the  number  of  school 
children,  the  number  of  houses,  etc.,  may  be  used  as  a 
guide  in  estimating  populations  outside  of  the  census 
returns.     It  is  particularly  necessary  not  to  place  undue 


306  TYPHOID  FEVER. 

confidence  upon  formulae  in  the  case  of  rapidly  growing 
towns  or  in  communities  where,  through  the  introduction 
of  manufacturing  or  some  other  great  cause,  there  have 
been  unusual  changes  in  the  population. 

The  United  States  Census  Bureau  now  prepares 
annual  estimates  of  population  for  all  the  large  cities  of 
the  United  States,  that  is,  for  those  which  have  a 
population  of  30,000  or  more,  and  by  reason  of  their 
official  character  these  estimates  are  more  and  more  com- 
ing to  be  used  for  the  purpose  of  calculating  death-rates. 

In  studying  the  records  of  death-rates  in  published 
reports,  one  should  be  careful  to  find  out  what  basis  of 
population  was  used  in  calculating  them.  For  instance, 
—  a  death-rate  for  the  year  1899  might  be  based  upon 
a^  population  estimate  nine  years  after  a  census.  The 
census  of  the  following  year  might  show  that  this 
estimated  population  was  far  from  the  truth,  and  that 
some  other  population  should  have  been  used.  In 
studying  old  records,  therefore,  it  is  wisest  to  recalculate 
the  rates,  using  the  number  of  deaths  as  given  and  the  new 
estimates  of  population  made  in  the  fight  of  later  census 
returns.  To  this  end  the  published  typhoid  statistics 
of  a  city  should  include  the  actual  number  of  deaths  as 
well  as  the  death-rates,  or  if  the  latter  only  are  given,  the 
population  used  in  computing  them  should  be  stated 
clearly. 

It  is  customary  to  use  but  a  single  figure  for  the  popu- 
lation for  any  one  year,  and  not  to  make  any  difference 
between  months.  The  estimated  population  in  the 
middle  of  a  year  is  taken  as  the  population  for  the 
entire  year. 


APPENDIX    IV. 

CORRECTED    DEATH-RATES. 

{From  the  Annual  Report  of  the  Massachusetts  State  Board 
of  Health,   1902.) 

The  State  of  Massachusetts  has  become  so  densely  settled,  so 
far  as  relates  to  its  urban  population,  as  to  require  a  better 
method  of  computing  the  death-rates  of  large  cities  than  that 
which  is  usually  employed,  when  it  is  desirable  to  compare  the 
death-rates  of  such  cities  with  each  other. 

The  following  tables  are  presented  for  the  purpose  of  showing 
the  method  of  comparing  the  death-rates  of  different  cities  with 
each  other,  when  the  conditions  as  to  the  relative  numbers  of 
persons  of  different  sexes  and  ages  are  not  the  same  in  each. 
The  crude  or  recorded  death-rate  of  any  city  for  a  given  year,  as 
obtained  by  comparing  the  existing  population  with  the  number 
of  deaths  in  the  year,  may  be  compared  with  the  death-rate  of  the 
same  city  for  any  other  year  or  series  of  years,  but  it  cannot  be 
compared  with  that  of  another  city,  for  the  same  year,  unless  the 
populations  of  the  two  cities  have  an  identical  relative  distribu- 
tion of  the  population  by  sexes  and  ages. 

For  example:  the  crude  death-rates  of  the  older  cities  and 
towns  of  the  Atlantic  sea-coast  cannot  properly  be  compared 
with  those  of  new  western  cities,  in  which  the  relative  number  of 
persons  of  young  and  healthy  ages  is  in  excess  of  that  in  the  former 
cities,  while  the  population  at  advanced  ages  is  also  correspond- 
ingly smaller.  For  this  reason  the  registrar-general  of  England 
has  devised  the  method  of  referring  the  figures  of  different  com- 
munities, cities  and  towns  to  some  standard  population,  such  as 
that  of  the  country  at  large,  or,  as  advised  by  other  experts,  to 
that  of  some  very  healthy  population,  like  that  of  Sweden. 

307 


3o8 


TYPHOID  FEVER. 


In  the  following  table  the  population  and  deaths  in  the  State 
at  large  are  assumed  as  a  standard,  and  the  death-rates  of  the 
cities  are  compared  with  this  standard.  The  method  is  fully 
explained  in  the  last  edition  of  Newsholme's  "Vital  Statistics." 

The  statistics  of  the  year  1900  are  here  selected  for  presenta- 
tion because  the  census  enumeration  was  taken  in  that  year. 
The  data  for  sexes  and  ages,  however,  were  only  published  for 
cities  having  a  population  of  25,000  or  more  in  each.  This 
includes  20  of  the  large  cities  of  Massachusetts. 

In  certain  cities  the  death-rate  is  unfavorably  influenced  by 
the  presence  of  public  and  private  institutions,  in  which  a  con- 
siderable number  of  non-resident  patients  are  treated  whose 
deaths  should  not  be  credited  to  the  death-rate  of  those  cities. 
An  allowance  has  therefore  been  made  of  419  deaths  of  such  non- 
residents in  Boston,  of  119  in  Worcester,  of  79  in  Taunton,  and 
of  90  in  Chelsea,  all  of  which  occurred  in  sixteen  public  and 
private  institutions  during  the  census  year  1900. 

'  For  the  purposes  of  this  comparison  a  mean  annual  mortality 
of  the  State  by  ages  and  sexes  for  the  three  years  1899,  1900  and 
1901  was  calculated  and  applied  to  the  population  of  each  city  in 
this  group.  This  mean  annual  rate  for  each  sex  and  age  is 
shown  in  the  following  table:  — 


DEATH-RATES   BY   SEXES   AND    AGES.     1899-1901. 


Ages. 


o-  S 

5-10 

10-15 

15-20 

20-25 


Males. 

Fe- 
males. 

Per- 
sons. 

58.41 
4-74 
2.84 

48.00 
4.60 
2.88 

53-21 
4.67 
2.86 

4.70 
6.71 

4-43 
5-94 

4-56 
6.30 

Ages. 


25-35 
35-45 
45-55 
55-65 
65  + 


Males. 


7.96 
10.48 
16.26 
30.96 
88.60 


Fe- 
males. 


7-31 

9.42 

14.20 

26.51 

82.78 


Per- 
sons. 


From  this  table  it  appears  that  the  death-rate  at  each  age 
period  between  5  years  and  55  years  was  less  than  that  of  the 
State  for  all  ages  (which  was  17.48  for  the  three  years).  Under 
5  years  and  over  55  the  death-rate  is  much  higher  than  the  com- 


APPENDIX  IV. 


309 


bined  death-rate  of  the  State.  If,  therefore,  the  proportion  of 
the  total  population  living  at  different  ages  differs  much  in 
different  cities  or  communities,  then  the  total  death-rates  at  all 
ages  will  also  differ,  independently  of  sanitary  conditions. 

The  same  rule  applies  to  sex  distribution.  At  all  of  the  age 
periods,  except  ages  10-15,  the  female  death-rate  is  lower  than 
that  of  the  male;  hence  an  excess  of  females  also  tends  to  lower 
the  general  death-rate  irrespective  of  sanitary  conditions. 


CENSUS 

OF    I 

poo. 

Age  Distribution  of  Populat 

ion  of 

Ages. 

Massachusetts. 

Holyoke. 

Salem. 

Males. 

Females. 

Males. 

Females. 

Males. 

Females. 

0—  5  years     . 

505 

501 

610 

618 

530 

520 

5—10  years     . 

457 

456 

550 

556 

506 

473 

10-15  years     . 

407 

411 

480 

498 

411 

427 

15-20  years     . 

411 

437 

448 

525 

405 

449 

20-25  years     . 

461 

534 

454 

627 

449 

519 

25-35  years     . 

921 

955 

849 

972 

842 

920 

35-45  years     . 

704 

708 

658 

643 

631 

710 

45-55  years     . 

470 

492 

398 

411 

448 

523 

55-65  years     . 

292 

334 

216 

244 

286 

377 

65  years  and  over 

224 

286 

83 

140 

220 

328 

Unknown    .    . 

23 

II 

12 

9 

13 

13 

4,875 

5,125 

4,758 

5,242 

4,741 

5,259 

10,000 

10,000 

10,000 

To  illustrate  this  principle  the  foregoing  table  is  presented, 
containing  the  distribution  of  the  population  by  sexes  and  ages 
in  the  State  at  large,  and  in  the  two  cities,  Holyoke  and  Salem. 

In  Holyoke  the  combined  population  at  ages  0-5  and  all  over 
55  constituted  19.  i  per  cent  of  the  whole  population,  while  that 
of  Salem  at  the  same  ages  was  22.6  of  the  whole.     In  the  case  of 


3IO 


TYPHOID    FEVER. 


Holyoke  the  percentage  of  the  population  at  these  ages  was  less 
than  that  of  the  State  for  the  same  ages,  notwithstanding  its  high 
birth-rate,  but  its  population  at  advanced  ages  is  relatively  small, 
as  is  usually  the  case  in  comparatively  new  cities.  In  Salem,  a 
much  older  city,  the  population  under  5,  and  also  that  which  is 
over  55,  is  greater  than  that  of  the  State  at  the  same  ages,  thus 
favoring  a  higher  death-rate  in  Salem  and  a  lower  one  in  Holyoke 
than  that  of  the  State  at  large. 

The  method  of  correcting  the  death-rates  for  sex  and  age  dis- 
tribution is  shown  in  the  following  tables:  — 


RECORDED  AND  CORRECTED  DEATH-RATES  PER  1,000 
PERSONS  LIVING  IN  MASSACHUSETTS  CITIES  OF 
MORE   THAN    25,000   INHABITANTS   IN    1900. 


I 

2 

3 

4 

5 

Cities  in  the  Order 
of  Their  Corrected 

Standard 
Death- 

Factor  for 
Correction 
for  Sex  and 

Recorded 
Death- 

Corrected 
Death- 

Compara- 
tive 

Death-Rates. 

rates. 

Age  Dis- 

rates. 

rates. 

Mortality 

tribution. 

1900. 

1900. 

Figure. 

Massachusetts 

17.48 

I.  000 

18.23 

18.23 

1. 000 

Brockton.    .    .    . 

16.27 

1.074 

13-85 

14.87 

0.816 

Maiden    .    . 

17.02 

1.027 

14-53 

14.92 

0.818 

Newton    .    . 

17.06 

1.024 

15.01 

15-37 

0.843 

Haverhill 

17.67 

0.989 

15-55 

15-38 

0.844 

Somerville   . 

17-30 

I.  010 

15-67 

15-83 

0.868 

Fitchburg    . 

17.02 

1.027 

15-67 

16.09 

0.883 

Chelsea    .    . 

17.77 

0.984 

16.42 

16.16 

0.886 

Lynn    .    .    . 

16.80 

1.040 

15-91 

16.55 

0.908 

Gloucester  . 

1733 

1.009 

17.00 

17-15 

0.941 

Cambridge  . 

16.54 

1.056 

16.54  ■ 

17.47 

0.958 

Springfield  . 

17-31 

I.  010 

18.93 

19. 12 

1.049 

Salem  .    .    . 

17-95 

0.974 

19.86 

19-34 

1.061 

Worcester    . 

16.56 

1.056 

18.33 

19.36 

1 .062 

Taunton  .    . 

16.89 

1-035 

19-43 

20.09 

1. 102 

Lowell .    .    . 

16.07 

1.088 

19.48 

21.19 

1-163 

Boston .    .    . 

16.26 

1-075 

20.08 

21.59 

1. 184 

New  Bedford 

17.07 

1.024 

21. 19 

21.70 

1. 190 

Lawrence    . 

16.09 

1.086 

20.40 

22. 15 

I.  215 

Fall  River  . 

15.90 

1.099 

21-53 

23.66 

1.297 

Holyoke  .    . 

15-55 

1. 124 

21.96 

24.68 

1-354 

APPENDIX  IV.  311 

In  this  table  the  Standard  Death-rate  signifies  the  death-rate 
at  all  ages  calculated  on  the  hypothesis  that  the  death-rates  at 
each  of  the  ten  age  periods  in  each  city  were  the  same  as  in  Mas- 
sachusetts during  the  three  years  1899-1901,  the  death-rate  at  all 
ages  in  Massachusetts  during  that  time  having  been  17.48  per 
1,000.  The  Factor  for  Correction  is  the  figure  by  which  the 
crude  or  recorded  death-rate  should  be  multiplied  in  order  to 
correct  for  variations  of  sex  and  age  distribution.  The  Corrected 
Death-rate  is  the  recorded  death-rate  multiplied  by  the  Factor 
for  Correction.  The  Comparative  Mortality  Figure  represents 
the  Corrected  Death-rate  in  each  city,  compared  with  the  Re- 
corded Death-rate  at  all  ages  in  Massachusetts  in  1900  taken  as 
1000. 

The  figures  in  this  column  (5)  may  be  read  as  follows:  after 
making  approximate  corrections  for  differences  of  age  and  sex 
distribution,  the  same  number  of  living  persons  that  gave  1,000 
deaths  in  Massachusetts  in  1900  gave  816  in  Brockton,  818  in 
Maiden,  1,354  in  Holyoke,  etc. 

The  first  column  in  the  table  is  obtained  by  assuming  that  the 
mean  mortality  in  Massachusetts  in  the  three  years  1899-1901 
prevailed  in  each  city.  The  age  and  sex  distribution  of  each  of 
these  cities  at  the  census  of  1900  being  known,  the  mean  mortality 
in  Massachusetts  in  1899-1901  is  applied  to  the  population  thus 
constituted,  and  the  result  is  the  series  of  death-rates  in  column  i. 
The  differences  in  the  death-rates  of  the  cities  in  this  column  are 
therefore  caused  only  by  the  difference  in  the  age  and  sex  distri- 
bution of  their  inhabitants. 

The  following  example  shows  the  method  of  obtaining  these 
standard  death-rates:  — 

The  population  of  Holyoke  in  1900  was  45,712;  the  total  num- 
ber of  calculated  deaths  in  Holyoke  was  711;  the  standard  death- 

.  r  71 1  X  1000 

rate  was,  therefore,    ' =  15.55. 

45,712 

Now  the  mean  annual  death-rate  of  Massachusetts  in  1899-1901 
was  17.48.  This  should  be  the  same  as  the  calculated  death-rate 
for  Holyoke,  which  was  obtained  by  applying  the  mean  annual 


312 


TYPHOID   FEVER. 


death-rate  of  Massachusetts  at  the  different  age  groups  to  the 
population  of  Holyoke  at  the  same  ages. 


Mean  Annual 

Death-Rate  in 

Massachusetts, 

Population  of 

Calculated  Num- 

1899-1901, per 

Holyoke. 

ber  of  Deaths 

Ages. 

1000  Living  at 

1900. 

in  Holyoke. 

Each  Group  of 

Ages. 

Males. 

Females. 

Males. 

Females. 

Males. 

Females. 

Under  5  years 

58.41 

48.00 

2,787 

2,824 

163 

135 

5-10  years     . 

4 

74 

4 

bo 

2,514 

2,542 

12 

12 

10-15  years     . 

2 

84 

2 

88 

2,194 

2,276 

6 

6 

15-20  years     . 

4 

70 

4 

43 

2,048 

2,400 

10 

II 

20-25  years     . 

6 

71 

5 

94 

2,075 

2,866 

14 

17 

25-35  years     . 

7 

96 

7 

31 

3,881 

4,445 

31 

32 

35-45  years     . 

10 

48 

9 

42 

3,006 

2,940 

31 

28 

45-55  years     . 

lb 

26 

14 

20 

1,818 

1,879 

30 

27 

55-65  years     . 

30 

q6 

26 

51 

9«5 

1,113 

30 

29 

65  years  and  over 

88 

60 

82 

78 

3«i 

642 

34 

53  . 

Unknown    .    . 

55 

41 

21,744 

23,968 

361 

350 

45,712 

711 

But  the  calculated  or  standard  death-rate  for  Holyoke  is  lower, 
as  shown  above,  which  must  arise  from  the  fact  that  the  distribu- 
tion of  ages  and  sexes  in  the  Holyoke  population  is  more  favorable 
than  in  the  State  at  large. 

The  standard  death-rate  in  Holyoke,  being  lower  than  that  of 
the  State,  must  be  raised  in  a  certain  ratio  in  order  to  bring  it  into 
comparison  with  that  of  the  State.  It  must  be  increased  in  the 
proportion  of  15.55  to  17.48. 

The  factor  for  correction  for  age  and  sex  distribution,  by 
which  the  recorded  death-rate  of  Holyoke  must  be  multiplied  in 
order  to   make  it   comparable   with    that  of   Massachusetts  is 


APPENDIX    IV.  313 

— —  =  1. 1 24.     We  have  employed  a  triennial  correction  figure 

15-55 

as  a  constant,  lia%'ing  the  census  year  1900  as  the  middle  year  of 

the  three.     Any  error  which  may  be  due  to  the  use  of  a  triennial 

correction  figure  instead  of  a  special  correction  figure  for  a  single 

year  is  so   small  that  it  may  practically  be   disregarded.     By 

multiplpng  the  recorded  death-rates  in  column  3  by  the  factors 

for  correction,  the  corrected  death-rates  in  column  4  are  obtained. 

These  are  the  death-rates  which  would  have  been  recorded  in 

each  town   had   its   population    been   identical,  so    far   as    age 

and    sex    distribution    are    concerned,    with    the   population   of 

Massachusetts. 


APPENDIX  V. 

BACTERIOLOGICAL  DESCRIPTION  OF  THE    TYPHOID 
BACILLUS. 

Name. 

B.  der  Abdominal  typhus,  Eberth:  Virchow's  Archiv.  LXXXI, 

1880. 
B.  typhosus,  Zopf:   Spaltpilze,  1885. 

Morphology. 

Slender  rods,  with  rounded  ends,  occasionally  occurring  as  fila- 
ments, actively  motile. 

Length,  i  to  3  yu;  diameter  0.5  to  0.8  n. 
,   Flagella,  peritrichiate,  8  to  12  in  number,  long  and  undulating. 

Spores  never  have  been  observed. 

Stains  readily  with  watery  dyes. 

Does  not  stain  by  Gram's  method. 

Killed  by  exposure  to  a  temperature  of  65°  C.  for  ten  minutes. 

Aerobic  and  facultatively  anaerobic. 

Nutrient  Broth. 

SUghtly  turbid;  no  pellicle. 

Gelatin  Plate. 

Deep  colonies:  roimd,  gray  to  yellowish  brown,  entire. 

Surface  colonies:  at  first  small,  punctiform,  becoming  flat,  round- 
ish, gray,  glistening,  with  irregular  borders;  microscopically, 
colorless,  translucent,  becoming  grayish  yellow,  darker  in  the 
center,  marmorated;  border  undulate  to  lobate;  strongly  refract- 
ing. 

No  liquefaction. 

Surface  growth,  thin,  whitish,  irregular. 

314 


APPENDIX  V.  315 

Gelatix  Stab. 
Line  of  puncture,  filiform,  beaded. 
Xo  liquefaction. 

'Milk. 
Xo  coagulation.     SHght  acidit}',  -^hich  occasionally  changes  after 
a  time  to  alkalinit}'. 

Litmus  Milk. 

Slight  acid  reaction;  variable,  no  coagulation. 

Potato. 

Growth  a  pure  white  glistening  streak,  thin  or  scarcely  ^-isible. 

Agar  Slant. 

Growth  thin  translucent,  smooth,  sUmy,  spreading,  —  well  marked 
after  24  hours  at  37°  C. 

Lactose  Litmus  Agar. 
Color  of  growth  bluish. 

Nitrate  Broth. 

Xitrates  reduced  to  nitrites. 

tsTDOL  Production. 

Indol  not  produced,  or,  if  so,  only  a  small  amount- 

Fermentation  Tests. 

Dextrose  broth.     Xo  gas  produced;  httle  acid. 
Lactose  broth.     X'o  gas  produced;  no  acid.   • 
Saccharose  broth.     X'o  gas  produced;  no  acid. 
-Maltose  broth.     Xo  gas  produced;  some  acid. 
Mannite  broth.     Xo  gas  produced;  some  acid. 

Xeuir-AL  Red  Glucose  Broth.     Xo  color  change. 

Reaction  TvIth  Anti -typhoid  Serum. 

Readily  agglutinated  by  highly  diluted  serum.  It  is  best  to  use 
a  powerful  senim  obtained  from  an  immuxdzed  animal  rather 
than  from  the  blood  of  a  t}"phoid  patient. 


3i6  TYPHOID  FEVER. 

Pfeiffer's  Test. 
This  consists  in  injecting  a  ten  times  fatal  dose  of  the  bacillus, 
together  with  a  small  quantity  of  serum  from  an  animal  highly 
immunized  against  the  typhoid  bacillus,  into  the  peritoneal 
cavity  of  a  guinea  pig.  If  the  suspected  organism  is  the  typhoid 
bacillus,  then  the  bacilli  are  converted  into  granular  masses 
(tested  by  removal  and  examination  of  a  little  peritoneal  fluid 
after  half  and  after  one  hour),  and  the  animal  does  not  die, 
while  a  control  animal,  injected  with  the  bacillus  alone,  dies. 

Similarity  to  other  Bacteria. 

The  typhoid  bacillus  in  many  respects  resembles  other  bacteria, 
most  of  which  are  of  intestinal  origin.  One  of  these  is  bacil- 
lus coli  communis,  or  B.  coli,  an  almost  constant  inhabitant 
of  the  intestines  of  warm-blooded  animals.  Because  of  this 
fact  it  is  an  organism  commonly  used  as  an  index  of  fecal  pol- 
lution. Complete  descriptions  of  these  various  allied  organ- 
isms are  given  in  most  works  on  Bacteriology. 


APPENDIX   VI. 

TESTS   FOR  THE   DIAGNOSIS   OF  TYPHOID   FEVER. 

The  Widal  Test. 

{From  a  Circular  of  Information  issued  by  the  Department  of 

Health  of  the  City  of  New  York.) 

The  investigations  of  Griiber,  Widal  and  others,  publislied  in 
1896,  show  that  the  blood  of  persons  suffering  from  or  having 
recently  had  typhoid  fever,  contains,  as  a  rule,  after  the  fifth  day 
of  the  disease,  substances  w^hich  when  added  to  a  broth  culture  of 
the  typhoid  bacilli  arrest  the  characteristic  movements  of  these 
organisms  and  cause  them  to  become  clumped  together  in 
masses. 

It  has  been  further  shown  that  occasionally  the  blood  of  per- 
sons suffering  from  other  diseases  possesses  this  peculiar  property; 
but  that  when  the  agglutinating  substances  are  present  in  these  it 
is  in  relatively  small  amount.  These  substances  are  also  occa- 
sionally present  in  small  amount  in  other  diseases  and  even  in 
health.  The  reaction  is,  therefore,  a  quantitative  rather  than  a 
qualitative  one. 

The  results  of  a  very  large  number  of  examinations  made  here 
in  New  York  and  elsewhere  show,  that  if  the  blood  contains 
agglutinating  substances  in  sufficient  amount  to  cause  a  prompt 
and  marked  reaction,  when  one  part  of  serum  or  blood  solution 
is  added  to  twenty  parts  of  a  culture  of  the  typhoid  bacillus,  the 
presence  of  a  previous  or  existing  typhoid  infection  may,  for  diag- 
nostic purposes,  be  practically  considered  as  established. 

In  estimating  the  diagnostic  value  of  a  negative  result  from  this 
test,  we  must  remember  that  the  reaction  is  rarely,  if  ever,  present 

317 


3l8  TYPHOID   FEVER. 

until  at  least  five  days  after  the  appearance  of  symptoms;  that' it 
is  occasionally  absent  in  cases  of  typhoid  fever  until  the  third  or 
fourth  week,  or  even,  until  convalescence  is  established;  that  when 
developed  it  may  disappear  after  a  few  days;  and  that  no  definite 
relation  between  the  severity  of  the  disease  and  the  degree  and 
time  of  development  of  the  substances  causing  the  reaction  has 
been  established.  For  these  reasons  a  single  negative  result  in 
any  suspected  ca^e  only  renders  doubtful  the  existence  of  typhoid 
fever.  In  those  cases  in  which  the  reaction  is  absent  after  the 
ninth  day,  it  may  be  reasonably  assumed  that  the  large  majority 
will  not  prove  to  be  typhoid  fever,  and  the  absence  of  the  reaction 
in  all  of  several  different  cases  of  a  suspected  group,  or  after 
repeated  examinations  in  any  single  case,  affords  evidence  of 
very  decided  value  in  excluding  the  diagnosis  of  typhoid  fever. 

Either  dried  blood  or  the  serum  obtained  from  a  blister  may 
be  sent  for  examination.  Outfits  for  preparing  dried  blood 
specimens  may  be  obtained  at  any  of  the  stations  of  the  Depart- 
°  ment  of  Health,  a  list  of  which  will  be  forwarded  on  request. 
Serum  outfits  may  be  obtained  at  any  of  the  Department's 
Borough  offices,  or  will  be  mailed  on  application. 

Directions  for  Preparing  Specimens  of  Blood.  The  skin  cov- 
ering the  lobe  of  the  ear  is  thoroughly  cleansed  and  then  pricked 
with  a  clean  needle  deeply  enough  to  cause  several  drops  of 
blood  to  exude.  Two  large  drops  are  then  placed  on  the  glass 
slide,  one  near  either  end,  and  allowed  to  dry  in  the  air  without 
being  spread  out  on  the  surface  of  the  slide.  The  specimens 
should  never  be  heated  or  treated  with  any  chemical  fixative. 
After  drying,  the  slide  is  to  be  replaced  in  the  holder  and  returned 
in  the  addressed  envelope  to  a  culture  station,  or  mailed  to  the 
laboratory.  The  blank  giving  the  history  of  the  case  must  be 
filled  out  in  full  and  forwarded  with  each  specimen.  The  data 
thus  obtained  are  for  record. 

Directions  for  Obtaining  Specimens  of  Serum  from  Blisters. 
The  shield  (designed  to  protect  the  blister  from  rupture)  is 
applied  to  the  skin  somewhere  on  the  anterior  portion  of  the  body. 
The  piece  of  canthos  plaster  is  then  fixed  within  its  center.     After 


APPENDIX  VI.  319 

10  to  12  hours  the  shield  is  removed  and  one  of  the  ends  of  the 
small  glass  tube  accompanying  the  outfit  is  introduced  into  the 
blister.  The  tube,  both  ends  of  which  should  be  open,  should  be 
held  so  that  the  end  inserted  is  higher  than  the  other,  to  allow  the 
serum  to  run  into  it.  After  the  tube  has  been  nearly  filled,  it  is 
removed  and  the  ends  sealed  by  holding  them  a  moment  in  a  gas 
flame.  Care  must  be  observed  not  to  heat  the  middle  portion  of 
the  tube,  and  thus  coagulate  the  serum.  The  tube  so  prepared 
is  then  placed  in  the  wooden  box  and  returned  in  the  addressed 
envelope  to  a  culture  station,  or  mailed  to  the  laboratory. 

A  report  on  the  results  of  the  examination  will  be  telephoned 
to  the  attending  physician  early  on  the  following  day,  where  his 
telephone  number  can  be  ascertained.  Reports  are  mailed  by 
I  P.M.  each  day,  and  should  reach  their  destination  the  same 
evening. 

Laboratory  Technique.  A  culture  of  typhoid  fever  bacilli  is 
obtained  from  an  authenticated  case  of  typhoid  fever,  and  this 
must  be  selected  with  care.  Not  all  races  of  typhoid  bacilli  give 
equal  results,  and  by  a  process  of  selection  a  culture  must  be 
found  that  gives  the  best  results  in  the  largest  number  of  cases. 
Having  obtained  a  satisfactory  culture  it  should  be  kept  in  a 
virile  condition  by  frequent  transfers  to  agar  tubes.  For  use 
fresh  bouillon  cultures  should  be  used,  —  that  is,  sub-cultures 
less  than  twenty  hours  old.  The  reaction  of  the  medium  shall 
be  not  far  from  the  neutral  point. 

A  drop  of  the  blood  to  be  examined  is  placed  upon  a  glass  slip, 
with  nine  drops  of  sterile  water  around  it,  and  the  whole  stirred 
with  a  sterile  platinum  wire  until  the  blood  has  been  well  mixed 
through  the  mass.  This  gives  a  1:10  dilution.  Occasionally 
higher  dilutions  are  used. 

A  drop  of  this  diluted  blood  is  then  added  to  a  drop  of  the 
culture  medium,  containing  the  living  typhoid  bacilli.  This 
gives  a  dilution  of  1:20,  the  dilution  generally  used.  The  cover 
glass  is  then  sealed  with  vaseline  and  placed  under  the  microscope, 
using  a  one-sixth  inch  objective,  and  the  material  examined  as  a 
"  hanging  drop,"  at  intervals  for  about  half  an  hour. 


320  TYPHOID    FEVER. 

In  a  typical  positive  reaction  the  bacilli  lose  motility  and  group 
themselves  in  clusters,  or  clumps.  This  agglutination  of  the 
bacilli  is  indicative  that  the  blood  is  derived  from  a  person  who 
has  or  who  has  recently  had  the  disease.  Agglutination  may 
occur  in  some  cases  in  high  dilutions;  in  others,  only  in  low  dilu- 
tions. But  low  dilutions  may  sometimes  show  positive  tests  in 
the  case  of  other  diseases,  and  even  in  the  case  of  well  persons; 
hence  the  test  is  not  always  final  and  deciding.  As  a  rule, 
however,  positive  tests  obtained  using  a  dilution  of  1:20  indicate 
a  positive  diagnosis. 

For  further  data  concerning  this  test,  and  the  agglutinating 
eflfects  of  the  paratyphoid  bacillus,  the  bacillus  of  dysentery,  etc., 
the  reader  is  referred  to  the  recent  works  on  pathological  bac- 
teriology. 

Ehrlich's  Diazo  Reaction  in  Urine.  The  presence  in  the  urine 
of  Ehrlich's  diazo  reaction  for  typhoid  fever  furnishes  an  early 
and  valuable  aid  in  the  diagnosis  of  typhoid  fever. 

The  test  is  performed  in  the  following  manner:  Equal  parts 
of  the  suspected  urine  and  the  following  solution  (saturated  solu- 
tion of  sulphanilic  acid  in  5  per  cent  hydrochloric  acid  40  parts; 
0.5  per  cent  solution  of  sodium  nitrite  i  part)  are  mixed  and  well 
shaken.  On  the  addition  of  a  few  drops  of  ammonia  a  brilliant 
rose  pink  color  should  appear,  if  the  case  be  one  of  typhoid  fever. 
The  twelve-hour  sediment  is  also  characteristic,  consisting  of  a 
dirty  gray  lower  layer  and  a  narrower  dark  olive  green  upper 
layer. 

This  reaction  is  present  in  the  urine  of  a  great  majority  of  all 
cases  of  typhoid  fever  at  some  time  in  their  course.  It  is  found 
earlier  than  the  Widal  reaction  in  the  blood,  appearing  on  from 
the  third  to  the  sixth  day  of  the  disease.  The  intensity  and  date 
of  appearance  of  the  reaction  appear  to  have  no  relation  to  the 
severity  of  infection.  In  a  number  of  instances  the  diazo  reaction 
has  been  present  in  undoubted  cases  of  typhoid  fever  in  which  no 
Widal  reaction  was  at  any  time  obtainable  from  the  blood.  No 
case  has  so  far  been  observed  in  which  the  Widal  reaction  was 
present  and  the  diazo  reaction  absent.     The  reaction  is  present 


APPENDIX  VI.  321 

in  its  greatest  intensity  at  about  the  tenth  day  of  the  disease.  It 
often  disappears  at  the  end  of  the  second  week,  and  is  almost 
invariably  absent  when  complete  defervescence  is  reached.  In 
relapses  the  reaction  usually  reappears,  but  if  the  reinfection  is 
mild,  it  may  be  absent.  In  second  or  third  attacks  of  the  disease, 
occurring  after  intervals  of  months  or  years,  the  reaction  is  present 
just  as  in  primary  attacks.  It  is  also  present  in  certain  other 
conditions;  these  are  severe  scarlet  fever  and  measles,  acute 
miliary  tuberculosis,  and  general  sarcomatosis  or  carcinosis. 
With  the  exception  of  miliary  tuberculosis,  however,  the  above 
conditions  are  usually  readily  distinguishable  from  typhoid  fever. 

Examination  of  the  Blood  for  the  Typhoid  Bacillus.  Coleman 
and  Buxton's  blood  test  is  described  on  page  322. 

By  the  use  of  this  test,  the  diagnosis  of  the  disease  can  be  made 
at  an  earlier  stage  than  with  the  Widal  test  alone. 


APPENDIX   VII. 

THE  BACTERIOLOGY  OF  THE  BLOOD  IN  TYPHOID 
FEVER.     AN  ANALYSIS  OF  1602  CASES.^ 

By  Warren  Coleman,  M.D.,  Professor  of  Clinical  Medicine, 
Cornell  University  Medical  College,  and  Assistant  Visiting 
Physician  to  Bellevue  Hospital,  New  York,  and  B.  H.  Buxton, 
M.D.,  Professor  of  Experimental  Pathology,  Cornell  University 
Medical  College,  New  York. 

During  the  last  six  years  we  have  made  bacteriological  exami- 
nations of  the  blood  in  123  cases  of  typhoid  fever  in  the  wards  of 
the  Second  Medical  Division  of  Bellevue  Hospital.  In  1904  we 
published  an  analysis  of  604  cases  of  typhoid  fever  (for  the  most 
part  collected  from  the  literature)  in  which  the  blood  had  been 
examined  bacteriologically.  Seventy-five  per  cent  of  these  cases, 
examined  at  all  stages  of  the  disease,  showed  the  presence  of  the 
typhoid  bacillus.  Bacteriological  examinations  of  the  blood  of 
typhoid  and  suspected  cases  have  been  made  routine  practice 
in  many  hospitals,  and  the  number  of  cases  reported  to  date, 
including  our  own,  reaches  a  total  of  1602.  The  present  analysis 
includes  all  the  cases  in  our  former  paper,  except  the  reports  of 
individual  cases. 

Methods.  We  usually  draw  10  cubic  centimeters  of  blood 
into  an  all-glass  syringe  from  a  vein  at  the  bend  of  the  elbow. 
In  our  earlier  experiments  (1901  to  1903)  we  used  broth  flasks, 
putting  2  to  3  cubic  centimeters  of  blood  into  each  100  cubic 
centimeters  of  broth.  Later,  on  learning  that  Busquet  and 
other  French  authors  had  had  extraordinary  success  by  using 
very  large  quantities  of  broth,  we  followed  their  method  of  dilu- 

'  From  the  American  Journal  of  the  Medical  Scieftces,  June,  1907. 

322 


APPENDIX  Vn.  323 

ting  each  cubic  centimeter  of  blood  in  about  200  cubic  centimeters 
of  broth,  but  the  results  were  not  appreciably  better  than  before. 
Since  August,  1906,  however,  we  have  had  very  marked  success 
with  ox-bile,  as  recommended  by  Conradi.  Ox-bile  not  only 
prevents  coagulation,  but  inhibits  the  bactericidal  action  of 
drawn  blood  and  affords  an  excellent  culture  medium  for  typhoid 
bacilli.  Our  tests  on  this  point  have  fully  confirmed  the  previous 
observations  of  Conradi,  Kayser  and  others. 

The  method  followed  has  been  to  take  ox-bile  90  cubic  centi- 
meters, glycerin  10  cubic  centimeters,  and  peptone  2  grams. 
The  mixture  is  distributed  into  small  flasks,  20  cubic  centimeters 
in  each,  and  sterilized.  Three  of  these  flasks  are  used  for  each 
examination,  about  3  cubic  centimeters  of  blood  being  run  into 
each.  The  flasks  are  then  incubated,  and  the  next  morning 
streaks  are  made  from  each  flask  over  the  surface  of  a  litmus- 
lactose-agar  plate.  If  microorganisms  are  present,  a  growth 
may  be  observed  in  flve  or  six  hours.  If  the  growth  does  not 
redden  the  medium  and  is  found  to  be  a  bacillus  resembling  the 
typhoid  organism,  it  is  tested  for  the  Widal  reaction  with  immune 
serum.  By  this  procedure  we  are  often  able  to  determine  if  the 
case  is  one  of  typhoid  fever  or  not  within  twenty-four  hours  after 
drawing  the  blood. 

Of  1602  tabulated  cases,  1197,  or  75  per  cent,  gave  a  positive 
result.  The  examinations  were  made  at  all  stages  of  the  disease 
and  by  different  methods.  Since  in  our  experience  the  bile 
method^  is  the  only  one  which  may  confidently  be  depended  upon, 
such  a  large  percentage  of  positive  results  goes  far  to  prove  that 
the  bacillus  is  present  in  the  blood  in  practically  all  cases  of 
typhoid  fever. 

Analysis  of  the  Cases  by  Weeks.  The  day  of  the  disease  upon 
which  the  examination  was  made  is  mentioned  in  1137  cases 
only.  To  be  more  exact,  this  represents  the  number  of  examina- 
tions, not  of  cases,  for  in  many  instances  more  than  one  examina- 
tion was  made  in  a  case. 

First  Week.     Of  224  examinations  in  the  first  week  of  the 

We  have  not  tried  the  glucose  method  of  Epstein. 


324  TYPHOID  FEVER. 

disease,  200  (8g  per  cent)  were  positive.  The  earliest  positive 
result  has  been  reported  by  Widal,  who  recovered  the  bacillus 
from  the  blood  on  the  second  day  of  the  disease.  The  reported 
positive  results  become  more  frequent  as  the  end  of  the  first  week 
is  approached,  only,  we  believe,  because  the  disease  is  not  sus- 
pected earlier,  and  the  examinations  made,  or  because  the  cases 
do  not  come  under  observation. 

Second  Week.  Of  484  examinations  made  in  the  second  week 
of  the  disease,  353  (73  per  cent)  were  positive. 

Third  Week.  Of  268  examinations  made  in  the  third  week  of 
the  disease,  178  (60  per  cent)  were  positive. 

Fourth  Week.  Of  103  examinations  made  in  the  fourth  week 
of  the  disease,  39  (38  per  cent)  were  positive. 

After  the  Fourth  Week.  Of  58  examinations  made  after  the 
fourth  week  of  the  disease,  exclusive  of  relapses,  15  (26  per  cent) 
were  positive. 

Very  few  statements  are  made  concerning  the  clinical  histories 
ojf  the  cases  in  and  after  the  fourth  week,  though  some  of  them  are 
reported  as  severe  and  of  long  duration.  As  in  our  first  analysis, 
the  percentage  of  positive  results  is  greatest  in  the  first  week  and 
steadily  declines  thereafter. 

We  have  already  called  attention  to  the  remarkably  successful 
results  of  Busquet  and  others,  who  recovered  the  bacillus  from 
the  blood  in  approximately  100  per  cent  of  their  cases.  Our 
results  since  the  adoption  of  the  bile  method  have  been  equally 
successful,  standing  out  in  marked  contrast  to  those  with  broth. 
In  all  we  have  used  this  method  in  34  cases.  As  a  rule,  the 
blood  was  examined  as  soon  as  a  case  of  fever  without  obvious 
cause  entered  the  hospital,  and  before  the  diagnosis  Was  estab- 
lished. Six  of  these  34  cases  were  diagnosticated  ultimately  as 
certainly  not  typhoid  fever;  3  of  the  cases  pursued  the  clinical 
course  of  typhoid  fever,  but  gave  neither  a  positive  blood  culture, 
nor  a  positive  serum  reaction  against  any  member  of  the  typhoid- 
colon  group.  In  fact,  after  examinations  of  urine,  feces,  opsonic 
index,  and  injections  of  tuberculin,  a  satisfactory  diagnosis  could 
not  be  made.     It  seems  only  fair  to  exclude  these  cases.      One 


APPENDIX  VII,  325 

case  ran  an  eleven-day  temperature,  the  maximum  being  loi 
degrees,  but  for  the  most  part  ranging  between  99  and  100 
degrees.  The  first  blood  culture  was  taken  on  the  eighth  day. 
There  was  a  difference  of  opinion  as  to  the  diagnosis.  The 
patient  had  an  old  tuberculous  process  at  one  apex.  This  case 
likewise  may  be  fairly  excluded.  "We  made  three  examinations 
of  his  blood. 

The  remaining  24  cases  were  typhoid  fever  clinically  and  by 
serum  reaction  and  all  gave  positive  bacteriological  results.  The 
examinations  were  made  from  the  fifth  to  the  twenty-first  day 
in  a  long-duration  case. 

The  various  series  oi  cases  in  the  table  giving  approximately 
100  per  cent  of  positive  bacteriological  results  are  too  numerous 
to  be  accidental.  They  compel  the  conclusion  that  the  typhoid 
bacillus  is  present  in  the  blood  in  ever}-  case  of  typhoid  fever 
and  that  failure  to  recover  it  is  due  to  error  of  technique.  The 
diminishing  percentages  of  the  larger  analysis  in  the  later  weeks 
of  the  disease  do  not  indicate,  then,  that  the  bacillus  has  dis- 
appeared from  the  blood  in  the  negative  cases,  but  point  rather 
to  diminishing  numbers  of  bacilli,  whose  presence  imperfect 
methods  have  failed  to  reveal.  All  investigators  except  Conradi 
are  agreed  that  the  bacillus  disappears  from  the  blood  at  or  about 
the  time  the  temperature  falls  to  normal.  Conradi  claims  that 
the  bacillemia  persists  into  convalescence.  We  have  repeatedly 
examined  the  blood  in  the  last  day  or  two  of  the  febrile  period 
and  not  once  have  we  recovered  the  bacillus.  Therefore,  it 
seems  probable  that  the  typhoid  bacillus  is  not  only  present  in 
the  blood  in  every  case  of  typhoid  fever^  but  that  it  is  present 
throughout  the  course  of  the  disease,  or  at  least  to  within  a  day 
or  two  of  complete  defer^'escence. 

The  Significance  of  the  Bacillemia.  If  future  observations 
confirm  the  conclusion  that  the  typhoid  bacillus  is  present  in 
the  blood  of  every  case  of  typhoid  fever  throughout  its  course, 
the  current  conception  of  the  pathogenesis  of  the  disease  should 
be  modified.  Typhoid  fever  can  no  longer  be  regarded  simply 
as   an  infection   of  the   body   with   typhoid   and   related   bacilli 


326  TYPHOID  FEVER. 

(Bacillus  paratyphosus,  etc.).  The  typhoid  bacillus  may  be 
present  in  the  body  and  actively  growing,  yet  the  patient  not 
have  typhoid  fever.  It  has  been  shown,  for  example,  that  the 
bacillus  may  live  and  multiply  in  the  intestine  of  healthy  per- 
sons. The  patient  is  infested  and  a  menace  to  others,  but  is 
not  infected.  The  number  of  cases  of  biliary  infection  with  the 
typhoid  bacillus,  without  a  previous  or  existent  typhoid  fever,  is 
fairly  large  and  is  increasing.  At  least  two  cases  of  cystitis, 
caused  by  the  typhoid  bacillus  in  persons  without  a  history  of 
typhoid  fever,  have  been  recorded.  (There  is  little  probability, 
however,  of  the  absorption  of  endotoxins  in  any  quantity  in 
cholecystitis  and  cystitis).  In  the  post-typhoid  bone  and  other 
inflammatory  lesions  the  lodgment  and  growth  of  the  bacillus 
do  not  produce  the  characteristic  symptoms  of  typhoid  fever,  in 
spite  of  the  fact  that  large  amounts  of  endotoxin  should  be  lib- 
erated and  absorbed  when  the  abscesses  are  multiple.  The 
very  term  used  to  describe  these  conditions,  "post-typhoid," 
indicates  that  the  typhoid  fever  per  se  has  subsided.  The  tem- 
perature curve  conforms  to  the  so-called  septic  type. 

Therefore,  it  seems  that  to  produce  typhoid  fever  the  bacillus 
must  not  only  be  present  in  the  body  and  growing,  but  that  it 
should  grow  in  a  situation  whence  it  has  free  access  to  the  blood. 
In  our  first  paper  we  expressed  the  opinion  that  in  typhoid  fever 
the  earliest  and  principal  seat  of  infection  is  the  blood,  and  that 
the  disease  should  be  regarded  as  a  bacillemia.  From  the  work 
done  by  one  of  us  on  the  absorption  of  the  typhoid  bacillus  from 
the  peritoneum,  and  from  the  fact  that  in  typhoid  fever  the  lymph 
nodes  and  spleen  contain  such  enormous  numbers  of  bacilli,  we 
are  disposed  to  modify  this  view  and  to  conclude  that  in  typhoid 
fever  the  bacillus  first  finds  its  way  from  the  alimentary  tract  to 
the  lymphopoietic  system,  including  the  spleen,  where  it  develops 
chiefly  and  from  which  it  invades  the  blood  stream.  We  think 
it  doubtful  whether  the  bacillus  multiplies  in  the  blood,  but  rather 
that  its  presence  there  represents  simply  an  overflow  from  the 
lymph  organs.  Under  this  interpretation  the  presence  of  the 
bacillus  in  the  blood  does  not. constitute  a  true  septicemia. 


APPENDIX  VII.  327 

The  absorption  experiments  above  referred  to  also  indicate  that 
destruction  of  the  typhoid  bacilli  proceeds  most  rapidly  in  the 
blood.  This  observation,  together  with  the  fact  that  the  bacille- 
mia  persists  throughout  the  disease,  suggests  the  following  view 
of  the  pathogenesis  of  typhoid  fever:  That  the  disease  is  caused 
by  the  destruction  of  vast  numbers  of  bacilli  in  the  blood,  with  the 
liberation  of  their  endotoxins,  and  the  consequent  reaction  on 
the  part  of  the  host.  When  the  endotoxins  are  liberated  elsewhere 
in  the  body,  e.g.,  in  abscesses,  the  symptomatology  is  not  that  of 
typhoid  fever. 

This  conception  of  the  nature  of  typhoid  fever  is  borne  out  by 
analogy.  It  is  known  that  Bacillus  paratyphosus  may  infect  the 
intestine  and  produce  the  clinical  picture  of  gastro-enteritis,  but 
that'  when  it  invades  the  lymph  organs  and  blood  it  produces  a 
disease  clinically  indistinguishable  from  typhoid  fever.  Diplo- 
coccus  lanceolatus  and  the  various  streptococci  furnish  similar 
analogies  in  that  they  produce  different  affections  according  to 
the  regions  they  attack. 

There  is  another  matter  to  which  we  would  call  attention  in 
this  connection.  The  idea  still  prevails  in  some  quarters  that 
the  course  of  typhoid  fever  may  be  influenced  and  even  shortened 
by  the  use  of  intestinal  antiseptics.  Such  opinion  is  based  on  an 
erroneous  conception  of  the  nature  of  typhoid  fever.  After 
invasion  of  the  body  proper  by  the  bacillus  the  battle-ground 
shifts  from  the  intestines  to  the  blood,  and  the  employment  of 
intestinal  antiseptics  with  the  idea  of  controlling  the  disease  is, 
to  say  the  least,  irrational. 

The  Relation  of  the  Bacillemia  to  the  Course  and  Types  of  the 
Disease.  Course.  The  analysis  of  the  cases  in  the  various  weeks 
of  the  disease  suggests  the  following  relation  of  the  bacillemia  to 
the  course  of  typhoid  fever;  In  the  earlier  stages  the  bacillus 
invades  the  blood  in  greatest  numbers.  Later,  as  the  disease  is 
approaching  a  favorable  termination,  the  diminution  in  the  num- 
ber of  bacilli  in  the  blood  is  simply  an  index  of  less  active  develop- 
ment in  the  lymphatics  and  spleen.  If  the  disease  in  any  case 
pursues  a  long-duration  course,  that  beyond  the  usual  three  weeks, 


328  TYPHOID  FEVER. 

the  bacillus  may  be  recovered  from  the  blood  as  long  as  the  tem- 
perature persists.  We  have  isolated  the  bacillus  late  in  such 
cases  repeatedly.  There  appears  then  to  be  a  definite  relation  in 
the  evolution  of  typhoid  fever  between  the  symptoms  and  the 
bacillemia.  The  increasing  intensity  of  the  symptoms  in  the 
earlier  period  of  the  disease  corresponds  to  active  growth  of  the 
bacilli.  They  invade  the  blood  stream  in  increasing  numbers 
and  are  there  destroyed.  Then  comes  the  stationary  period, 
when  the  ratios  of  growth  and  destruction  appear  uniform.  The 
steep-curve  period  corresponds  to  a  diminishing  bacillemia,  and 
defervescence  to  the  complete  disappearance  of  bacilli  from  the 
blood.  In  other  words,  the  duration  of  the  febrile  movement  is 
measured  by  the  persistence  of  the  bacillemia.  As  already 
stated,  Conradi  is  the  only  investigator  who  claims  that  the  bacil- 
lemia  continues   into   convalescence. 

Ewing  has  expressed  the  opinion  that  "the  degenerative 
changes  in  the  liver,  kidneys,  and  lymphoid  organs,  while  initi- 
ated by  the  bacterial  proteids,  possess  certain  self-perpetuating 
tendencies,"  and  therefore  "typhoid  fever  is  a  combination  of  a 
specific  bacterial  intoxication  and  a  somewhat  peculiar  auto- 
intoxication, the  former  element  being  more  prominent  early,  the 
other  later  in  the  disease,  but  both  developing  simultaneously." 
We  are  unable  to  accept  this  conception  of  the  pathogenesis  of 
typhoid  fever.  It  appears  inconsistent  with  the  facts  developed 
by  our  studies.  We  maintain  that  exclusive  of  convalescence, 
which  should  be  regarded  as  the  period  of  repair,  degenerative 
changes  occur  only  in  the  presence  of  active  growth  and  destruc- 
tion of  bacilli.  We  have  shown  that  convalescence  is  established 
immediately  upon  the  disappearance  of  the  bacilli  from  the  blood, 
and  there  are  reasons  to  believe  that  it  is  not  interrupted  except  as 
the  result  of  a  fresh  growth  of  bacilli.  While  the  bacilli  disappear 
from  the  blood  at  or  just  before  defervescence,  it  is  improbable 
that  all  the  bacilli  in  the  body  have  been  destroyed.  Otherwise, 
relapses  and  post-typhoid  inflammatory  lesions  would  be  impos- 
sible. Unless  then  it  can  be  shown  that  the  symptoms  of 
typhoid    fever    would    persist    after    the    complete    destruction 


APPENDIX  VII.  329 

of  all  bacilli  in  the  body,  we  think  that  Ewing's  position  is 
untenable. 

Types.  The  bacillemia  apparently  bears  no  relation  to  the 
type  or  severity  of  the  disease  except  in  so  far  as  regards  numbers 
of  bacilli.  The  bacillus  is  found  in  the  blood  equally,  but  not 
with  the  same  persistence,  in  the  mild  as  in  the  severe  cases,  and 
in  the  cases  of  short  as  well  as  of  long  duration.  We  have  found 
the  bacillus,  for  example,  in  cases  lasting  ten,  thirteen,  and  four- 
teen days,  and  on  the  twenty-seventh  day  of  a  long-duration  case. 
The  importance  of  the  definite  establishment  of  the  nature  of 
these  short-duration  cases  can  scarcely  be  overestimated  from  the 
epidemiological  standpoint.  The  serum  reaction  has  done  much 
to  clear  up  their  diagnosis,  but  the  final  proof  has  remained  for 
the  bacteriological  examination  of  the  blood.  We  make  only  a 
brief  reference  to  these  cases  here,  as  we  shall  deal  with  them  at 
length  in  the  near  future. 

Relapses.  The  blood  has  been  examined  bacteriologically  by 
various  investigators  in  t,^  relapses.  The  typhoid  bacillus  has 
been  recovered  in  30  (90  per  cent)  of  the  cases.  We  suggested 
in  1904  that  a  relapse  in  typhoid  fever  is  due  to  reinvasion  of  the 
blood  by  the  bacillus.  Reinvasion  of  the  blood  with  destruction 
of  the  bacilli  probably  causes  the  symptoms  of  a  relapse,  but  the 
underlying  conditions  which  inaugurate  active  development  of 
the  bacilli  after  their  growth  has  once  been  brought  under  control 
are  unknown.  We  feel  safe  in  asserting  that  a  relapse  is  not  due 
to  reinfection  with  the  typhoid  bacillus  from  the  intestine  as  the 
result  of  intestinal  trauma  brought  about  by  dietary  irregu- 
larities. We  do  not  wish  to  intimate,  however,  that  we  believe 
the  occurrence  of  a  relapse  is  entirely  independent  of  diet  or  to 
be  understood  as  advocating  a  liberal  diet  in  typhoid  fever. 
We  are  not  prepared  as  yet  to  express  an  opinion  upon  this 
subject. 

The  Relation  of  the  Bacillemia  to  the  Senim^  Reaction.  In  our 
former  paper  we  stated  that  it  would  seem  likely  on  a  priori 
grounds  that  the  typhoid  bacillus  is  always  present  in  the  blood 
before  the  serum  reaction  develops,  for  the  reason  that  endotoxins 


330 


TYPHOID   FEVER. 


should  be  liberated  before  the  agglutinins  could  be  formed.     The 
following  table  clearly  illustrates  the  truth  of  this  conclusion: 

TABLE  SHOWING  RELATION  OF  BACILLEMIA  TO  SERUM 
REACTION. 


Author. 


Hirsh . 

Jochmann 

Roily 

Duffy 

Buxton  and  Coleman 


Bacillus  Found  and 

Widal  Reaction 

Negative. 


23 
5 

16 
18 
32 

94 


Of  the  55  cases  of  Hirsh  and  ourselves,  which  showed  the 
presence  of  the  bacillus  in  the  blood  before  the  serum  reaction 
could  be  obtained,  23  were  in  the  first  week,  26  in  the  second, 
and  6  in  the  third.  The  diagnostic  value  of  these  results  in  cases 
in  which  only  one,  or  a  few,  serum  tests  have  been  made  is 
important.  A  negative  serum  reaction  may  have  no  significance 
even  in  the  third  week  of  the  disease.  Moreover,  Dr.  Hastings 
has  shown  in  some  of  our  cases,  especially  those  of  short  duration, 
that  a  positive  serum  reaction  may  be  present  for  only  two  or 
three  days.  If  the  serum  reaction  had  not  been  tested  on  those 
days,  the  result  would  have  been  recorded  as  negative  throughout 
the  disease.  For  the  complete  diagnosis  of  an  obscure  case  by 
the  serum  reaction  the  tests  should  be  made  daily. 

Conclusions,  i.  The  typhoid  bacillus  is  present  in  the  blood 
of  every  case  of  typhoid  fever  throughout  its  course. 

2.  The  bacillemia  in  typhoid  fever  does  not  constitute  a  true 
septicemia,  but  it  represents  an  overflow  of  bacilli  from  the 
lymphopoietic  organs. 

3.  The  clinical  picture  of  typhoid  fever  results  only  from  infec- 
tion of  the  lymphopoietic  organs  by  the  typhoid  bacillus,  with 


APPENDIX  VII.  331 

invasion  of  the  blood  stream  and  destruction  there  of  vast  num- 
bers of  bacilli. 

4.  The  endotoxins  of  the  typhoid  bacillus  are  not  cumulative 
in  action,  and  convalescence  from  the  typhoid  fever  per  se  is 
established  within  a  few  days  after  the  disappearance  of  the 
bacUli  from  the  blood. 


APPENDIX   VIII. 

EXAMINATION    OF    WATER    FOR    THE    TYPHOID 
BACILLUS. 

The  isolation  of  the  typhoid  fever  bacillus  from  infected  water 
is  a  matter  of  such  difficulty  that  less  than  a  dozen  authentic 
cases  of  its  finding  are  on  record.  Nevertheless,  theoretically, 
it  can  be  done,  and  it  is  not  unlikely  that  the  future  may  reveal 
some  important  developments  in  this  direction.  Savage,  in  his 
recent  excellent  vi^ork  on  the  Bacteriological  Examination  of 
Water  Supplies,^  has  described  various  methods  that  have  been 
used.  These  may  be  found  also  in  Prescott  and  Winslow's 
'/Elements  of  Water  Bacteriology." 

There  are  three  steps  involved  in  the  process:  — 

1.  Concentration,  vs^hereby  any  typhoid  bacilli  that  may  be 
scattered  through  a  large  volume  of  water  are  brought  together 
in  a  small  volume  within  the  compass  of  present  methods  of 
examination. 

2.  Isolation  of  the  organism  in  pure  culture. 

3.  Identification  of  the  organism  by  the  application  of  differ- 
ential tests. 

Concentration.  A  simple  method  of  concentration  is  to  filter 
a  large  quantity  of  the  sample  to  be  examined  through  a  sterile 
Pasteur  filter  and  brush  the  accumulated  sediment  into  a  small 
quantity  of  sterile  water.  This  method  is  not  satisfactory,  as  it 
increases  all  other  kinds  of  bacteria  in  the  same  proportion. 

The  use  of  the  centrifuge  has  been  recommended  in  place  of 
filtration,  but  it  has  no  especial  advantage.  Sometimes  chemi- 
cals are  used  to  produce  a  coagulent  that  during  its  precipi- 
tation will  entangle  the  bacteria  and  carry  them  to  the  bottom. 

1  Published  by  P.  Blakiston's  Son  &  Co. 
332 


APPENDIX  VIII.  333 

Anti-typhoid  serum  has  also  been  used  in  a  somewhat  similar 
manner. 

Other  methods  depend  upon  the  greater  motility  of  the  typhoid 
bacillus  than  most  of  the  other  bacteria  likely  to  be  found  in 
water,  and  attempts  have  been  made  to  separate  the  typhoid 
bacilli  from  the  others  by  taking  advantage  of  this  characteristic. 

Various  forms  of  enrichment  methods  have  been  suggested, 
that  is,  certain  substances  are  added  to  the  water  with  the  object 
of  facilitating  the  multiplication  of  the  typhoid  germ,  or  of  inhib- 
iting the  development  of  other  forms.  Phenol  broth,  caffeine, 
etc.,  have  been  used  for  this  purpose;  the  latter  with  most  suc- 
cess, but  the  sterilized  ox-bile  has  been  found  to  be  more  satis- 
factory than  either. 

Isolation  in  Pure  Culture.  For  this  stage  of  the  process  some 
kind  of  solid  medium  is  necessary  in  connection  with  the  method 
of  plate  culture.  Among  the  media  used  are  nutrient  gelatine, 
nutrient  agar,  semi-solid  media  composed  of  both  gelatine  and 
agar,  phenol  agar,  lactose  litmus  agar,  bile-salt  agar,  neutral 
red  agar,  etc.  The  Drigalski-Conradi  agar  is  more  satisfactory 
than  any.  Savage  [loc.  cit.]  describes  the  use  of  this  medium  as 
follows: 

Drigalski-Conradi  Agar.  "This  medium  was  primarily  in- 
tended for  the  isolation  of  the  typhoid  bacillus  from  excreta; 
it  is,  however,  of  great  value  in  water  bacteriology.  It  is  pre- 
pared as  follows: 

"  (i)  Agar  Preparation.  —  To  3  pounds  of  finely-cut  beef,  add 
2  liters  of  water;  allow  the  mixture  to  stand  until  next  day.  Boil 
the  expressed  meat-juice  for  one  hour  and  filter;  add  20  grams 
peptone  sicca  (Witte),  20  grams  nutrose,  10  grams  sodium 
chloride,  boil  the  whole  again  for  one  hour  and  then  filter.  Now 
add  70  grams  bar  agar,  boil  for  three  hours  (or  one  hour  in  the 
autoclave),  renders  Hghtly  alkaline  (indicator,  litmus-paper), 
filter,  boil  for  half  an  hour. 

"(2)  Litmus  Solution.  —  Litmus  solution  (Kubel  and  Tie- 
mann),  260  cubic  centimeters;  boil  for  ten  minutes;  add  30  grams 
of  chemically  pure  milk-sugar  and  boil  for  fifteen  minutes.     Add 


334  TYPHOID   FEVER. 

the  hot  litmus  milk-sugar  solution  to  the  liquid  agar  solution 
(cooled  to  60°  C);  shake  well;  render  it  again  faintly  alkaline; 
then  add  4  cubic  centimeters  of  a  hot  sterile  solution  of  10  per 
cent  water-free  soda  and  20  cubic  centimeters  of  a  freshly  pre- 
pared solution  of  0.1  gram  crystal  violet  (B.  Hochst)  in  100  cubic 
centimeters  warm  sterile  distilled  water.  The  result  is  a  meat- 
water  peptone  nutrose  agar,  containing  13  per  cent  litmus  and 
o.oi  per  1,000  crystal  violet.  The  medium  can  be  kept  in 
tubes,  or  in  small  flasks  containing  enough  for  three  or  four 
plates.  It  is  sufl&cient  to  sterilize  once  in  current  steam  for 
thirty  minutes." 

"  The  Petri  dishes  used  should  be  large  (diameter  15  to  20  centi- 
meters), and  about  20  to  25  cubic  centimeters  should  be  poured 
into  each.  The  medium  should  never  be  less  than  2  millimeters 
thick.  After  pouring,  the  plate  should  remain  uncovered  for  at 
least  one  hour,  until  the  steam  has  evaporated  and  the  agar  is 
quite  stiff.  A  sterile  glass  rod  bent  near  one  end  at  right  angles 
is  used  for  smearing  the  plates.  After  the  plates  are  spread  they 
should  remain  open  for  at  least  half  an  hour,  until  the  agar 
surface  is  completely  dry.  This,  according  to  the  authors, 
is  important,  moisture  causing  the  colonies  to  run  together. 
Saprophytic  air  organisms  are  said  not  to  grow,  on  account 
of  the  crystal  violet,  so  that  air  contamination  does  not  take 
place." 

"  After  fourteen  to  sixteen  hours  at  37°  C. —  twenty-four  hours 
in  some  cases  —  the  colonies  can  be  distinguished  from  one 
another.  The  coli  colonies  are  red,  not  transparent,  and  have  a 
diameter  of  2  to  6  millimeters,  but  considerable  variation  in  size 
and  degree  of  color  are  met  with.  The  B.  typhosus  colonies  are 
blue,  with  a  violet  tinge;  they  are  transparent  and  resemble  dew- 
drops,  and  have  a  diameter  of  i  to  3  millimeters,  seldom  larger." 

Identification.  This  stage  of  the  process  consists  in  ascer- 
taining if  the  organism  isolated  conforms  to  the  differential  tests 
for  typhoid  fever  in  accordance  with  the  characteristics  set  forth 
on  page  314. 

Regarding  this  process  Savage  says:  — 


APPENDIX  VIII.  335 

"  It  is  now  generally  advocated  that  all  suspicious  organisms 
should  first  be  roughly  tested  as  to  their  ability  to  be  agglutinated 
by  typhoid  serum  in  moderate  dilution.  If  no  agglutination 
takes  place,  they  may  be  at  once  rejected.  If  a  positive  reaction 
is  obtained,  cultural  tests  are  carried  out,  while  a  more  exact 
series  of  agglutination  tests  is  made.  In  this  way  it  is  possible 
to  greatly  lighten  the  labor  of  examining  a  large  number  of  sus- 
picious colonies.  The  colonies  under  investigation  are  either  at 
once  examined  or  after  subcultivation.  For  the  first  method  a 
little  of  the  colony  is  transferred  to  a  cover-slip  emulsified  in  a 
drop  of  broth,  and  an  equal  quantity  of  serum  added,  the  whole 
test  being  carried  out  on  the  cover-slip.  For  the  second  method 
the  colonies  are  inoculated  into  nutrient  broth,  and  the  agglu- 
tination tests  performed  next  day,  after  growth  has  taken  place. 
The  latter  is,  on  the  whole,  preferable.  The  broth  cultures  which 
show  a  positive  result  are  then  ready  for  further  investigation; 
the  others  are  rejected." 

"  Great  as  are  the  improvements  which  have  taken  place  in  the 
facility  with  which  typhoid  bacilli  can  be  isolated  from  specifically 
infected  excreta,  with  none  of  the  different  methods  can  it  be  said 
that  the  isolation  of  the  bacillus  from  an  infected  water-supply 
is  other  than  a  difficult  and  unsatisfactory  procedure,  and  only 
under  very  favorable  conditions  can  success  be  hoped  for." 

"It  is  advisable  to  try  several  methods,  and  in  the  writer's 
opinion  the  following  would  probably  be  the  most  serviceable 
procedure: 

''(a)   Examine  5  to  10  liters  by  Drigalski's  method." 

"(b)  Take  i  liter  of  the  water  and  precipitate  the  organisms 
by  one  of  the  precipitation  methods.  The  precipitated  organisms- 
are  distributed  over  a  large  series  of  Drigalski-Conradi  plates." 

"(c)   Examine  another  liter  by  the  caffeine  method." 

"  All  suspicious  colonies  obtained  from  the  three  methods  (and 
the  total  number  may  be  large)  are  subcultivated  into  broth, 
and  incubated  at  37°  C,  until  next  day.  They  are  all  then 
examined  in  hanging  drop,  and  those  which  show  actively  motile 
bacilli  are  tested  with  antityphoid   serum.     A  fairly  powerful 


336  TYPHOID    FEVER. 

serum  should  be  available,  and  a  dilution  of  not  less  than  i  per 
cent  should  be  employed." 

"  All  those  which  fail  to  show  agglutination  are  rejected,  while 
those  reacting  are  each  subcultivated  into  litmus-milk,  glucose 
neutral-red  broth,  and  lactose-peptone  solution." 

"  All  the  organisms  giving  cultural  characters  in  these  media 
which  accord  with  those  of  B.  typhosus  are  fully  worked  out. 
The  tests  should  include  accurate  and  extended  agglutination 
tests  with  highly  dilute  sera.  Such  organisms  will  usually  be 
found  to  be  very  few  in  number." 


APPENDIX  IX. 

PRESENT  STATUS  OF  WATER  ANALYSIS  IN  CON- 
NECTION WITH  THE  INVESTIGATION  OF 
TYPHOID    EPIDEMICS.! 

By  Ernest  C.  Levy,  M.D.,  Chief  Health  Officer,  Richmond,  Va. 
{Formerly  Director  of  Laboratory  of  City  Water  Department.) 

The  frequency  with  which  the  writer  receives  inquiries  from 
physicians  in  regard  to  examining  water  for  typhoid  bacilli  is 
sufl&cient  ground  for  believing  that  a  brief  paper  dealing  with 
the  subject  here  chosen  will  have  a  certain  amount  of  usefulness. 
Knowing  that  where  a  given  water  is  responsible  for  an  outbreak 
of  typhoid  fever  the  bacilli  of  this  disease  must  have  been  present 
in  the  water,  and  having  only  rather  general  ideas  of  the  methods 
of  bacteriological  examination  of  water,  what  more  natural  than 
that  the  average  physician  should  consider  the  actual  finding  of 
typhoid  bacilli  as  the  natural  and  crucial  test  in  these  cases?  It 
is  the  object  of  this  paper  to  show  why  this  direct  method  of  solv- 
ing the  question  is  not  applicable,  and,  furthermore,  to  point  out 
briefly  just  what  the  water  expert  of  to-day  does  in  these  cases, 
provided  he  can  get  his  client  to  understand  something  of  the 
matter  —  which  end,  in  the  writer's  own  experience,  can  always 
be  accomplished  by  a  plain  statement  of  the  facts  in  the 
case. 

The  first  difficulty  connected  with  placing  the  responsibility 
for  an  outbreak  of  typhoid  fever  by  means  of  direct  bacterio- 
logical examination  for  the  detection  of  B.  typhi,  lies  in  the  fact 
that,  assuming  the  water  to  have  been  the  actual  cause,  it  is 

!  Reprint  from  Virginia  Medical  Semi-Monthly,  Nov.  lo,  1905. 
337 


338  TYPHOID  FEVER. 

impossible  to  get  a  sample  of  the  right  water  for  examination. 
The  minimum  period  of  incubation  of  typhoid  fever  is  eight  days, 
with  ^n  average  period  of  two  weeks.  Hence,  assuming  a  water- 
supply  to  become  infected,  it  is  not  until  two  weeks  later  that  a 
sufficient  number  of  cases  of  the  disease  have  developed  to  attract 
considerable  attention,  and  allowing  (a  liberal  estimate)  a  week 
more  for  the  physician  or  health  officer  to  reflect  on  the  subject 
and  get  into  communication  with  the  bacteriologist,  it  is  three 
weeks  altogether  before  the  investigation  is  started.  It  is  self- 
evident  that,  unless  the  pollution  is  a  continuous  one  (which  is 
not  usually  the  case)  the  failure  to  find  typhoid  bacilli  at  this 
late  date  cannot  be  taken  as  indicating  that  the  water  was  not 
originally  infected  and  gave  rise  to  the  outbreak. 

Coming  now  to  the  question  of  the  actual  examination  of  water 
for  B.  typhi,  it  is  not  at  all  difiicult  to  explain  why  our  methods 
are  so  imperfect.  In  almost  every  instance  where  a  stream 
becomes  infected  by  typhoid  bacilli  this  stream  receives  at  all 
t^mes  the  fecal  dejecta  of  a  number  of  persons,  and  it  is  only  when 
one  of  these  individuals  develops  typhoid  fever  that  the  bacilli 
of  this  disease  are  added  to  the  water,  along  with  the  continued 
discharges  of  a  number  of  unaffected  persons.  Now,  even  the 
dejecta  of  the  typhoid  patient  himself  contain  B.  coli  (the  normal 
inhabitant  of  the  intestinal  canal)  in  probably  greater  numbers 
than  B.  typhi,  while  still  larger  numbers  of  the  former  organism 
continue  to  enter  the  stream  in  the  stools  of  the  healthy  inhabi- 
tants of  the  watershed.  We  must,  therefore,  realize  that  almost 
invariably  a  water  which  has  become  infected  with  B.  typhi  has, 
along  with  these  organisms,  an  immensely  larger  number  of 
B.  coli,  the  only  exception  to  this  being  where  a  water  has  become 
infected  by  the  urine  of  a  typhoid  patient  but  is  otherwise  unpol- 
luted —  obviously  a  most  unusual  condition.  Besides  this,  a 
water  so  polluted  as  the  one  we  are  considering  in  our  typical 
case  is  certain  to  contain  large  numbers  of  bacteria  of  other  kinds, 
so  that  for  every  typhoid  bacillus  present  there  are  probably  an 
immense  number  of  bacteria  of  other  varieties. 

Let  us  assume  a  concrete  illustration  for  the  sake  of  making 


APPENDIX  IX.  339 

clearer  the  problem  which  confronts  the  bacteriologist  in  these 
cases.  A  water  would  surely  be  seriously  infected  if  each  glass- 
ful contained  20  typhoid  bacilli,  yet,  since  an  ordinary  drinking 
glass  holds  about  200  cubic  centimeters,  in  this  case  there  would 
be  only  a  single  typhoid  bacillus  in  each  10  cubic  centimeters  of 
the  water.  Such  a  water  would  almost  certainly  contain  at  least 
200  bacteria  of  other  kinds  per  cubic  centimeters  or  2000  in  the 
10  cubic  centimeters.  In  our  hypothetical  case,  therefore,  for 
each  typhoid  bacillus  there  would  be  2000  other  bacteria. 

Under  such  conditions  let  us  see  what  would  be  the  chance  of 
finding  typhoid  bacilli.  In  the  routine  method  of  plating  on 
gelatine,  it  would  be  necessary  to  make  ten  plates  of  one  cubic 
centimeter  each  in  order  to  get  a  single  colony  of  B.  typhi  (assum- 
ing the  typhoid  bacilli  to  be  evenly  distributed  through  the  water), 
and  after  all  the  colonies  have  developed  there  are  no  character- 
istics by  which  a  typhoid  colony  can  be  picked  out  on  sight,  while 
it  is  obviously  impossible  to  make  the  necessary  detailed  study  of 
so  large  a  number  of  colonies  as  would  be  necessary  to  identify 
the  typhoid  colony  from  others  resembling  it.  If  instead  of 
gelatine  we  use  agar  and  incubate  at  37°  C,  a  smaller  number 
of  total  colonies  will  develop,  but  even  here  it  would  be  impos- 
sible to  tell  if  one  of  these  was  B.  typhi,  except  by  a  most 
tedious  and  practically  impossible  detailed  study  of  hundreds 
of  colonies. 

Evidently,  then,  simple  plating  is  not  to  be  considered  as  a 
means  of  detecting  typhoid  bacilli  in  water,  and  we  are  brought 
to  look  into  whether  there  can  be  found  some  differential  method 
which  will  allow  the  typhoid  bacilli,  if  present,  to  develop,  while 
restraining  the  numerous  other  forms  which  must  always  be  con- 
ceived as  being  present.  Many  methods  of  this  sort  have  been 
suggested  from  time  to  time,  but  not  one  of  them  is  to  be  relied  on, 
the  chief  difl&culty  being  that  the  colon  bacillus,  always  present, 
is  much  hardier  than  the  typhoid  bacillus,  and  no  means  are  yet 
known  of  inhibiting  the  growth  of  the  former  and  still  permitting 
the  latter  to  proliferate.  It  must  be  made  clear  that  there  is  no 
difl&culty  in  differentiating  B.  coli  from  B.  typhi  when  cultures 


340  TYPHOID   FEVER. 

of  each  are  at  hand,  but  the  problem  is  to  obtain  the  latter  at  all 
in  the  presence  of  large  numbers  of  the  former  and  large  num- 
bers of  bacteria  of  still  other  kinds. 

Recognizing  that  one  of  our  difficulties  is  the  fact  that  so  large 
an  amount  of  water  must  be  examined  to  find  even  a  single 
typhoid  bacillus,  it  has  been  recommended  to  pass  a  considerable 
amount  of  water  through  a  porcelain  filter  and  take  for  examina- 
tion some  of  the  scrapings  from  the  filter,  which  will  then  con- 
tain, in  small  bulk,  all  the  bacteria  originally  present  in  the 
water.  As  a  matter  of  fact  this  in  no  wise  lessens  our  troubles, 
for  we  now  have  an  enormously  increased  number  of  B.  coli 
and  other  bacteria  to  deal  with,  and  this,  as  pointed  out  above, 
is  our  greatest  difficulty  after  all. 

If,  following  any  of  the  very  doubtful  methods  which  have 
been  proposed,  the  bacteriologist  at  last  secures  what  he  sus- 
pects may  be  a  culture  of  B.  typhi,  the  further  task  of  making 
certain  of  this  point  is  by  no  means  an  easy  one.  B.  typhi  is 
distinguished  largely  by  negative  characteristics,  both  morpho- 
logical and  Cultural,  nor  is  it  pathogenic  in  a  true  sense  for  any 
of  our  laboratory  animals.  Even  the  serum  reaction,  lauded 
as  specific  when  first  brought,  has  come  to  be  recognized  as 
a  test  demanding  the  utmost  care  in  technique  and  in  inter- 
pretation. 

Owing,  then,  to  the  difficulties  above  hastily  outlined,  an  expe- 
rienced man  in  this  branch  of  sanitary  science  will  not  undertake 
to  examine  a  water  at  all  for  B.  typhi,  or  at  any  rate  he  will  stake 
nothing  on  the  result.  But,'  while  the  problem  cannot  be  solved 
in  this  direct  manner,  still  it  is  possible  in  nearly  every  in- 
stance to  arrive  at  results  in  a  different  way,  and  this  true 
method  of  approach  is,  after  all,  of  far  greater  value  than  a 
mere  finding  or  not  finding  of  typhoid  bacilli  in  the  water  could 
possibly  be. 

The  correct  way  of  solving  the  problem,  as  matters  stand,  is  to 
make  a  thorough  study  of  each  specific  case  which  arises,  along 
well  recognized  lines.  Briefly,  this  includes  a  sanitary  survey 
of  the  watershed,  a  study  of  the  epidemic  itself,  and  a,  bacterio- 


APPENDIX  IX.  341 

logical  and  chemical  examination  of  the  water.  The  sanitary 
survey  is  to  be  regarded  as  an  indispensable  factor  in  every  case 
of  importance,  and  as  such  it  cannot  be  entrusted  to  anyone  who 
has  not  had  special  training  in  just  this  kind  of  work.  Each 
case  presents  its  own  peculiarities,  and  some  point  which  it  is 
impossible  to  foresee  may  give  the  due  to  the  whole  situation. 

Along  with  this  sanitary  survey,  inquiry  should  be  made  into 
the  special  features  of  the  epidemic  itself.  To  do  this  thoroughly 
is  the  work  of  weeks,  or  even  months  in  the  case  of  large  com- 
munities and  extensive  epidemics,  but  sufficient  information  for 
practical  purposes  may  frequently  be  gained  in  a  few  hours  of 
intelligent  study  in  smaller  communities,  especially  if  the  local 
physicians'    records   are   fairly    complete. 

This  visit  to  the  seat  of  the  trouble,  moreover,  enables  us  to 
judge  of  just  what  samples  we  wish  to  have  for  analysis  and  to 
collect  these  under  the  best  conditions  and  with  proper  precau- 
tions. It  also  enables  us  to  start  certain  parts  of  the  bacterio- 
logical work  on  the  spot,  which  is  a  matter  of  no  little  moment 
if  at  some  distance  from  the  laboratory.  The  tests  which  will  be 
applied  are,  in  a  broad  sense,  for  the  determination  of  fecal  pollu- 
tion in  general.  Both  chemistry  and  bacteriology  are  called 
upon,  but  the  chief  thing  is  the  detection  of  intestinal  bacteria. 

After  getting  together  all  the  facts  both  of  the  analysis  and  of 
the  sanitary  survey  and  special  study,  a  careful  consideration  of  all 
the  data  thus  available  will,  in  almost  every  instance,  lead  to  a 
thoroughly  trustworthy  opinion.  It  is  just  at  this  part  of  the 
work  that  judgment  and  experience  come  most  into  play.  The 
data  at  hand  are  to  an  expert  in  this  line  what  the  previous  history, 
symptoms  and  physical  signs  are  to  the  physician  in  arriving  at  a 
diagnosis,  and  each  reaches  his  final  opinion  by  a  careful  weighing 
of  all  the  evidence  and  not  by  blind  reliance  upon  any  isolated 
fact. 

This  simile  may  be  carried  further.  Certain  cases  of  disease 
may  be  diagnosticated  by  a  laboratory  test  of  material  secured 
from  the  patient,  as,  for  instance,  is  possible  by  a  sputum  examina- 
tion in  cases  of  pulmonary  tuberculosis,  but  no  physician  would 


342  TYPHOID   FEVER. 

care  to  take  the  responsibility  of  treating  a  case  of  consumption 
merely  on  the  evidence  thus  afforded,  without  examining  the 
patient  and  learning  a  great  deal  about  his  general  condition 
and  his  environment.  Just  so,  the  water  expert  may  often  be 
able  to  decide  by  analytical  methods  whether  or  not  the  water 
is  polluted,  but  knowledge  so  gained  is  always  of  a  general  char- 
acter, and  personal  study  of  the  case  on  the  ground  is  necessary 
for  the  correction  of  existing  conditions. 

We  may  apply  our  simile,  furthermore,  to  negative  cases. 
Where  a  sputum  exarnination  does  not  show  tubercle  bacilli,  but 
where  the  patient  is  nevertheless  seriously  ill,  the  examination 
will  show  little  of  what  the  real  condition  is.  So  with  water, 
finding  that,  so  far  as  a  mere  laboratory  examination  can  ever 
show,  the  water  is  all  right,  but  if,  in  spite  of  this,  typhoid  fever 
has  been  very  prevalent,  our  examination  is  of  value  merely  by  the 
probable  elimination  of  the  water  as  a  cause,  but  it  has  thrown 
no  light  whatever  on  what  is  responsible  for  the  trouble.  And, 
again,  our  work  would  be  incomplete  and  misleading  where  the 
water  was  only  one  of  several  causes.  By  means  of  a  personal 
survey,  if  the  water  was  found  not  responsible,  or  responsible 
only  in  part,  the  search  would  be  continued  to  arrive  at  every 
factor  in  the  case. 

The  main  points  may  be  briefly  summed  up  as  follows: 
(i)   No  satisfactory  method  is  known  for  the  detection  of  B. 
typhi  in  water. 

(2)  Were  such  a  method  known,  it  would  be  of  limited  appli- 
cation on  account  of  the  fact  that  when  an  outbreak  of  typhoid 
fever  leads  to  an  investigation,  the  water  supposed  to  have  been 
infected  is  no  longer  available  for  examination. 

(3)  Although  the  direct  detection  of  B.  typhi  in  water  is  impos- 
sible, yet  the  importance  of  bacteriological  and  chemical  exami- 
nation of  the  suspected  water  must  not  be  underestimated,  but 
it  should  be  combined  with  a  thorough  sanitary  survey  of  the 
field,  and  a  competent  study  of  the  phases  of  the  epidemic.  This 
will  almost  invariably  solve  the  question  whether  the  outbreak 
was  caused  by  drinking-water. 


APPENDIX  IX.  343 

(4)  This  method  of  attacking  the  problem  has  the  further 
advantage  of  throwing  light  on  the  sanitary  quahty  of  the  water 
in  question  apart  from  the  special  outbreak  of  typhoid  fever,  and, 
moreover,  if  it  is  found  that  the  water  is  not  responsible,  or  respon- 
sible only  in  part,  full  information  will  be  gained  along  many  lines, 
thereby  suggesting  the  steps  to  be  taken  for  future  protection. 


APPENDIX  X. 

THE   VIABILITY   OF   THE   TYPHOID    BACILLUS 
UNDER    NATURAL    CONDITIONS.^ 

By  Herbert  D.  Pease,  M.D.,  Director  New  York  State  Hygienic 
Laboratory,  Albany,  N.  Y. 

Simple  of  solution  as  this  subject  may  appear  to  be  to  the  unin- 
itiated, it  is  in  reality  one  which  has  occupied  the  attention  of 
bacteriologists  and  engineers  for  many  years.  However,  upon 
certain  aspects  of  the  subject  much  has  apparently  been  accom- 
plished in  the  last  five  years. 

"  That  the  subject  is  of  importance  is  quite  evident  to  those  who 
have  followed  the  results  of  the  studies  of  outbreaks  of  typhoid 
fever  published  during  the  last  half  decade.  Such  studies  are 
demonstrating  more  and  more  that  epidemics  of  the  disease  are 
caused  by  unusual  combinations  of  natural  and  artificial  condi- 
tions which  cannot  be  foreseen  or  foretold,  and  which  can  only 
be  prevented  by  directing  special  attention  in  two  directions  — 
first,  toward  the  great  public  improvements  in  water  purification, 
sewage  disposal  and  milk  production  and  distribution;  and,  sec- 
ondly, toward  the  proper  hygienic  management  of  each  case  of 
the  disease. 

This  review  will  not  attempt  to  consider  the  latter  aspect  of 
the  subject  in  which  the  relation  of  the  typhoid  bacillus  to  the 
infected  patient  would  naturally  come  under  discussion,  but  will 
deal  with  the  fate  of  the  typhoid  bacillus  as  it  passes  from  such  a 
patient  out  into  nature. 

I  will  first  discuss  some  of  the  available  evidence  as  to  the  fate 

*  From  Medical  Review  of  Reviews,  New  York,  September,  1907. 
344 


APPENDIX  X.  345 

of  the  bacillus  typhosus  when  deposited  in  various  kinds  of  natural 
soils  or  earths. 

Firth  and  Horrocks  ^  reviewed  the  work  done  on  this  phase  of 
the  subject  down  to  1902,  and  concluded  that  the  results  were 
too  contradictory  and  unsatisfactory  to  be  accepted.  They 
took  to  demonstrate  the  fate  of  bacillus  typhosus  in  moist  and 
dry  soils  of  various  kinds  under  natural  conditions,  such  as  the 
presence  and  absence  of  direct  sunlight  and  the  effect  of  washing 
of  the  soils  by  rains.  Their  results  are  of  great  interest  and 
importance. 

They  found  that  the  typhoid  bacillus  had  a  long  life,  of  at  least 
two  months,  in  the  various  soils  when  the  same  were  kept  moist; 
that  they  showed  no  tendency  to  multiply  in  such  soils  or  to  grow 
in  any  direction;  that  they  could  be  washed  by  water  for  at  least 
18  inches  through  fine,  closely  packed  earth  without  cracks  or 
fissures;  that  the  presence  or  absence  of  organic  matter  or  sewage 
in  the  soil  did  not  materially  affect  its  existence,  either  favorably 
or  otherwise;  that  when  any  of  the  kinds  of  typhoid-contami- 
nated soils  or  earths  were  allowed  to  dry  so  as  to  form  dust,  the 
typhoid  bacillus  could  be  found  living  in  it  after  25  days,  and 
that  the  dust  blown  from  such  dirt  contained  living  typhoid 
bacilli. 

They  likewise  found  that  122  hours  of  direct  sunlight  during 
21  days  was  not  sufficient  to  kill  the  typhoid  bacillus  present  in 
soils.  They  also  ascertained  that  the  freezing  of  soil  containing 
typhoid  bacilli  for  periods  of  several  days  did  not  completely  kill 
these  bacteria. 

In  none  of  the  experiments  made  by  these  authors  were  attempts 
made  to  determine  quantitative  viabiHty  as  well  as  qualitative, 
and  they  are  open  to  this  objection. 

RuUmann  '  found  that  the  typhoid  bacillus  lived  for  at  least  a 
year  and  a  half  in  otherwise  sterile  earth  and  gravel,  but  in  that 
time  had  died  out  in  sand.     The  numbers  were  greatly  reduced, 

'  Firth  and  Horrocks:  British  Medical  Journal,  1902,  Vol.  92,  p.  936.' 
^  Rullmann:    Centralblatt    jur    Bakteriologie,    Erst    Abt;    Originale, 
XXXVIII,  p.  380. 


346  TYPHOID  FEVER. 

however,  in  all,  and  the  reduction  was  greater  in  the  earth  than  in 
the  gravel. 

Levy  and  Keyser  ^  claim  to  have  found  living  typhoid  bacilli 
in  clayey  garden  soil,  which  had  been  manured  with  the  contents 
of  a  water-tight  privy  into  which  typhoid-infected  stools  had  been 
deposited  five  months  previously. 

From  the  results  of  these  investigators,  it  would  appear  that 
all  forms  of  moist  human  excrement,  dirt,  soil,  sand,  or  gravel 
favor  the  viability  of  the  typhoid  bacillus,  while  even  the  same 
materials  in  a  dry  state  support  its  existence  for  a  considerable 
period,  often  over  a  month.  It  would  also  appear  that  freezing 
and  direct  sunlight  have  but  little  eifect  upon  the  typhoid  bacillus 
in  soils,  and  that  they  can  be  washed  for  a  considerable  distance 
through  well-packed  earth  and  retain  life. 

These  conclusions  of  laboratory  investigations  are  in  entire 
harmony  with  the  known  facts  concerning  the  origin  of  numerous 
epidemics  of  typhoid  fever.  In  many  of  these  cases  it  has  been 
shown  that  typhoid  discharges  thrown  upon  the  surface  of  the 
ground,  or  buried  superficially  during  the  winter,  and  which 
have  remained  in  these  locations  for  several  months,  undergoing 
freezing  and  more  or  less  exposure  to  sunlight,  have  finally  been 
carried  into  waters  for  potable  purposes  and  have  produced  wide- 
spread epidemics.  The  New  Haven,  Conn.,  epidemic  of  1901 
was  brought  about  in  this  way.  Many  other  instances  of  a 
.  similar  kind  could  be  quoted. 

When  we  come  to  the  consideration  of  the  experiments  on  the 
viability  of  the  typhoid  bacillus  in  water  and  sewage,  the  results 
are  found  to  be  somewhat  different. 

In  water  the  typhoid  bacillus  is  subject  to  conditions  and  agen- 
cies of  a  physical,  chemical  or  biological  character.  The  physical 
agencies,  such  as  gravity,  sunlight  and  temperature,  probably 
play  a  most  important  part  in  rendering  water  an  unfavorable 
soil  for  the  existence  of  the  typhoid  bacillus,  but  chemical  agencies, 
such  as  the  presence  of  metals  or   inorganic  compounds,  absence 

^  Levy  and  Kayser:  CentralblaU  fur  Bakteriologie,  Erste  Abt.;  Orig., 
XXXIII,  489. 


APPENDIX  X.  347 

of  oxygen  and  usual  organic  matter,  likewise  play  a  considerable 
role  in  this  direction  under  certain  circumstances,  while  the  bio- 
logical agencies,  such  as  the  indirect  or  direct  antagonism  of 
other  bacteria  and  of  protozoa,  likewise  aid  materially  in  the 
destruction  of  these  pathogenic  bacteria. 

One  of  the  most  potent  factors  in  the  elimination  of  typhoid 
bacilli  from  water  is  sedimentation.  The  effect  of  this  agency  is 
so  well  known  and  consistently  recognized  that  it  is  not  necessary 
to  dwell  upon  it  at  length.  Sedimentation  was  the  agency  to 
which  Jordan  ^  attributed  a  large  part  of  the  purification  of  the 
Chicago  Drainage  Canal  and  the  Illinois  river.  This  force,  of 
course,  acts  in  inverse  proportion  to  the  amount  of  current  or 
motion  in  a  body  of  water.  Bissell  ^  has  stated  that  he  found  as 
many  colon  bacilU  in  the  waters  of  Niagara  River  below  Niagara 
Falls  as  above  it.  The  fate  of  the  typhoid  bacillus  after  it  has 
reached  the  bottom  of  a  body  of  water  has  not  been  studied  to 
any  great  extent.  The  solution  of  the  problem  has  not  great 
practical  importance  except  in  connection  with  the  matter  of  the 
pollution  of  edible  shellfish,  such  as  oysters  and  clams. 

Savage  ^  studied  the  effect  of  what  he  calls  tidal  mud  upon  the 
typhoid  bacillus,  and  found  that  the  latter  can  survive  fairly 
readily  for  two  weeks  in  tidal  mud,  but  after  this  period  their 
numbers  rapidly  diminish.  He  believes  that  the  examinations 
of  mud  when  obtainable  form  a  better  index  of  the  pollution  of  a 
stream  or  other  body  of  water  than  the  examination  of  the  water 
itself. 

That  direct  sunlight,  and  even  diffuse  daylight,  had  a  marked 
destructive  effect  on  typhoid  bacilli,  as  well  as  other  bacteria  in 
water,  has  been  well  recognized  since  the  early  work  of  Buchner. 
He  concluded  that  direct  sunlight  is  a  more  potent  factor  in  redu- 

^  Jordan:  Journal  of  Experimental  Medicine,  1900,  V,  271. 

*  Bissell:  Proceedings  American  Public  Health  Association,  1903, 
XXIX,  360. 

^  Savage:  Journal  oj  Hygiene,  1905,  Vol.  5,  p.  146. 

*  Buchner:  Centralblatt  fur  Bakteriologie,  XI,  781.  Quoted  by  Wheeler: 
Journal  of  Medical  Research,  1906,  XV,  277. 


348  TYPHOID  FEVER. 

cing  the  number  of  bacteria  in  natural  bodies  of  water  than  sedi- 
mentation. 

Procacci  exposed  water  in  deep  cylinders  to  the  nearly  vertical 
rays  of  the  sun,  and  found  that  after  three  hours  the  water  in  the 
cylinders  was  sterile  to  the  depth  of  one  foot,  while  at  a  depth  of 
two  feet  the  typhoid  bacilli  were  unaffected. 

Clark  and  Gage  ^  found  that  typhoid  bacilli  in  a  thin  layer  of 
water  were  destroyed  by  the  direct  sunlight  in  one  hour,  and  that 
when  they  were  exposed  in  bottles  of  water  their  extinction  was 
accomplished  in  five  hours. 

Wheeler^  has  shown  that  diffuse  daylight  has  a  detrimental 
action  on  bacillus  typhosus  in  waters  contained  in  glass  bottles. 

Weinzirl '  has  recently  shown  that  direct  sunlight  has  an  even 
more  powerful  germicidal  action  than  has  been  shown  by  previous 
experimenters.  The  defects  in  former  methods  of  testing  were 
caused  by  the  deflection,  reflection  and  absorption  of  the  sun's 
rays  by  the  glass  vessels,  etc.,  used  to  maintain  the  specimens 
free  from  contamination  by  foreign  bacteria. 

While  sunlight  unquestionably  has  a  very  destructive  effect 
upon  typhoid  bacilli  in  water  under  most  natural  conditions,  its 
failure  to  seriously  affect  these  bacteria  when  the  latter  were 
placed  in  earth  and  dirt,  as  shown  by  the  Firth  and  Horrock's 
tests,  already  referred  to,  indicates  that  there  must  be  some  other 
condition  than  the  mere  presence  of  the  sunlight  which  gives 
material  aid  to  its  disinfecting  action  when  the  bacilli  are  in 
water.  This  will  be  again  referred  to  when  the  effects  of  the 
presence  and  absence  of  dissolved  oxygen  in  the  water  is  taken 
up  for  consideration. 

The  effects  of  different  degrees  of  temperature  on  typhoid 
bacilli  in  water  is  most  interesting.  As  is  well  known,  the  opti- 
mum temperature  for  their  growth  in  culture  media  is  that  of  the 
human  body. 

^  Clark  and  Gage:  Annual  Report  Massachusetts  State  Board  of 
Health,  1902,  275. 

'  Wheeler:  Journal  of  Medical  Research,  1906,  XV,  269. 

'  Weinzirl :  Journal  Infectious  Diseases.     Supplement  III,  May,  1907. 


APPENDIX  X.  349 

Clark  and  Gage  ^  found  that  -when  in  water  it  could  resist  a 
temperature  of  80°  C.  for  five  minutes.  However,  they  found 
that  the  optimum  temperature  for  the  \'iability  of  the  bacillus  in 
water  was  20-22°  C,  or  the  so-called  room  temperature,  and 
that  37°  C,  or  the  body  temperature,  exerted  a  detrimental  effect. 
This  has  been  confirmed  by  Conradi  and  Bolton  ^  and  by 
Wheeler,^  who,  in  addition,  has  shown  that  the  room  tempera- 
ture is  more  favorable  to  typhoid  bacilli  in  water  than  is  that  of 
the  refrigerator.  He  also  states  that  temperatures  approximating 
0°  C,  and  32°  F.,  are  decidedly  detrimental  to  these  bacteria 
in  at  least  three  classes  of  water. 

Smith  and  Swingle  *  state  that  the  critical  temperature  for  the 
life  of  bacteria  is  about  0°  C. 

One  of  the  first  tests  of  the  effect  of  actual  freezing  upon 
bacillus  typhosus  was  made  by  Prudden  ^  in  1887.  By  the 
methods  of  testing  which  he  used,  namely,  to  freeze  small  amounts 
of  water  containing  typhoid  bacilli,  he  found  that  they  lived  in 
ice  for  103  days. 

Later  Park  ^  repeated  these  experiments,  but  made  quantita- 
tive as  well  as  qualitative  tests,  and  determined  that  the  decrease 
in  the  numbers  of  the  typhoid  bacilli  was  exceedingly  rapid  during 
the  first  few  days  or  weeks.  At  the  end  of  three  weeks  less  than 
I  per  cent  were  alive. 

Zeit  ^  also  repeated  Prudden's  experiment,  and  found  that  the 
typhoid  bacilli  were  completely  killed  by  freezing  in  24  hours. 

Clark  and  Gage  ^  operated  with  much  larger  volumes  of  both 
water  and  sewage.     They  have  shown  that  the  typhoid  bacillus 

*  Clark  and  Gage :  Loc.  Cit. 

'  Conradi  and  Bolton:  Centralblati  Jur  Bakterwlogw,  Erste  Abt.;  Orig., 
XXXW,  203. 

3  WTieeler:  Loc.  Cit 

4  Smith  and  S-ningle:  Science,  1905,  N.  S.,  Vol.  XXI,  481. 

*  Prudden:  Medical  Record,  1887,  31,  p.  341. 

^  Park:  Journal  Boston  Society  Medical  Science. 
^  Jordan,  Russell  and  Zeit:  Journal  of  Infectious  Diseases,  1904,  I,  660. 
8  Clark  and   Gage:   Annual   Report  Massachusetts   State   Board  of 
Health,  1902,  280. 


350  TYPHOID   FEVER. 

is  killed  rapidly  in  both  the  freezing  process  and  by  low  tem- 
peratures just  short  of  freezing. 

Many  other  experiments  were  made  by  them  in  which  the 
typhoid  bacillus  was  not  introduced  into  the  operations,  but 
from  the  results  of  which  conclusions  as  to  the  effect  of  freezing 
on  the  typhoid  bacillus  in  water  under  natural  conditions  might 
with  propriety  be  drawn. 

Thus  they  found  that  from  95  to  99  per  cent  of  all  the  water 
bacteria,  and  all  of  the  colon  bacilli  in  either  water  or  sewage, 
were  removed  by  freezing. 

Samples  of  ice,  and  water  under  the  ice,  were  taken  by  them 
from  the  polluted  Merrimac  River  at  points  varying  from  three 
to  eight  and  a  half  miles  from  the  outlets  from  the  sewers  of  a 
city  of  90,000  inhabitants,  and  the  ice  had  less  than  0.3  per  cent 
of  the  number  of  bacteria  present  in  the  water  under  it,  and  no 
colon  bacilli  were  found  in  the  ice. 

Clark  ^  believes  that  in  the  process  of  freezing,  the  bacteria, 
along  with  particles  of  dirt,  substances  in  suspension  and  some 
of  the  mineral  constituents  of  the  water,  are  expelled  into  the 
underlying  water.  He  thinks,  therefore,  that  the  physical  con- 
dition of  the  water  while  freezing  is  of  great  importance,  as  this 
expulsion  takes  place  most  satisfactorily  when  the  water  is 
quiet. 

Wheeler  ^  obtained  very  similar  results  to  those  quoted  in  his 
laboratory  tests  of  freezing  typhoid  bacilli  in  relatively  small 
amounts  of  water.  However,  he  does  not  consider  Clark's 
explanation  of  the  causation  of  the  decrease  in  the  numbers  of 
bacteria  in  ice  by  expulsion  as  the  correct  one.  He  floated  porce- 
lain capsules  containing  some  of  the  same  typhoid-inoculated 
water  as  was  in  the  pails  they  were  floating  in,  and  found  that  the 
typhoid  bacilli  were  killed  as  completely  and  rapidly  in  the  cap- 
sules as  in  the  surrounding  ice.  He  also  obtained  about  as  com- 
plete destruction  of  the  typhoid  bacilli  in  the  underlying  water  in 
the  pails  as  in  the  ice.     However,  his  work  was  done  on  small 

'  Clark:  Proceedings  American  Public  Health  Association,  XXVII,  204. 
»  Wheeler:  Loc.  Cit. 


APPENDIX  X.  351 

volumes  of  water,  previously  sterilized  by  heat  and  laboratory 
conditions,  while  Clark's  and  Gage's  work  had  been  done  under 
more  natural  conditions,  in  large  volumes  of  water. 

Wheeler  obtained  samples  of  ice  and  water  from  Lake  Cham- 
plain  at  distances  varying  from  30  to  several  hundred  feet  from 
the  sewer  outlets  of  the  city  of  Burlington.  In  the  samples  col- 
lected but  30  feet  from  the  sewer  outlets  there  were  microscopic 
evidences  of  sewage.  Bacillus  coli  was  not  found  in  any  of  the  ice 
samples,  but  was  present  in  large  numbers  in  the  underlying  water. 

Smith  and  Swingle  ^  obtained  a  percentage  destruction  of  over 
91  in  their  laboratory  freezing  tests  of  the  typhoid  bacillus  in 
bouillon.  They  believe,  from  freezing  experiments  done  on  other 
species  of  bacteria,  that  when  a  few  organisms  out  of  a  culture 
show  a  special  resistance  to  the  freezing,  that  this  resistance  is  due 
to  absence  of  water  in  the  protoplasm  of  those  particular  bacteria, 
and  that  they  behave,  therefore,  like  endospores,  although  the 
species  may  be  one  in  which  no  endospores  are  to  be  found. 
Prudden,  Park  and  others  quoted  found  a  small  percentage  of 
the  typhoid  bacilli  in  their  cultures  more  resistant  than  the 
majority,  and  this  endospore-like  formation  may  be  the  expla- 
nation. 

All  the  authors  unite  in  the  conclusion  that  repeated  freezings 
and  thawings  are  more  destructive  to  typhoid  bacilli  than  the 
single  freezings. 

There  exists  one  reported  instance  in  which  not  only  was 
typhoid  fever  apparently  transmitted  to  well  persons  by  means  of 
ice,  but  in  which  the  investigators  believed  that  they  isolated 
typhoid  bacilli  from  the  ice  in  question. 

Hutchins  and  Wheeler^  reported  the  occurrence  of  39  cases 
of  typhoid  fever  in  the  St.  Lawrence  State  Hospital  at  Ogdens- 
burg,  N.  Y.,  under  conditions  which  led  them  to  state  with 
some  degree  of  certainty  that  the  disease  was  due  to  the  use  of 
ice  taken  from  the  St.  Lawrence  River. 

^  Smith  and  Swingle:  Loc.  Cit. 

*  Hutchins  and  Wheeler:  American  Journal  Medical  Science,  1903, 
Vol.  126,  p.  680. 


352  TYPHOID  FEVER. 

They  examined  clear  ice  taken  from  the  river  five  months  pre- 
viously, which  had  been  stored  in  one  particular  icehouse, 
the  ice  from  which  they  had  suspected  as  being  the  cause  of  the 
disease.  In  this  ice  were  particles  of  dirt,  and  from  these  they 
isolated  in  pure  culture  several  colon  bacilli,  and  one  which  they 
considered  bacillus  typhosus. 

If  Clark's  theory  concerning  the  elimination  of  particles  of  dirt, 
etc.,  from  still  water  as  it  freezes  is  correct,  and  it  is  generally 
accepted,  then  this  ice  must  have  been  formed  when  the  water 
was  in  active  motion,  or  the  ice  was  flooded  with  the  infected 
water  and  opportunities  for  the  exclusion  of  the  dirt  prevented, 
or  under  some  other  very  unusual  condition. 

Ice  had  been  cut  from  this  location  for  the  twelve  years  prior  to 
the  outbreak,  and  no  typhoid  fever  traceable  to  it  had  been 
observed.  It  is  of  special  significance  that  all  the  ice  suspected 
of  causing  the  disease  came  from  one  particular  icehouse,  although 
all  were  filled  with  ice  from  the  same  general  location.  The 
conclusion  would  seem  to  be  irresistible  that  the  pollution  of  this 
ice  came  about  in  some  very  special  manner,  the  true  nature  of 
which  the  authors  were  unable  to  determine. 

Hill,^  in  a  report  on  the  ice  supply  of  the  city  of  Boston, 
remarks  that  the  purification  of  polluted  water,  which  takes  place 
during  the  process  of  freezing  and  including  the  subsequent 
three  weeks,  is  equivalent  to  the  filtration  of  that  water  by  the 
most  efficient  slow  sand  filters.  This  opinion  is  in  harmony 
with  those  expressed  by  Sedgwick^  and  others. 

But  little  is  known  of  the  effect,  if  any,  of  the  natural  mineral 
constituents  of  water  upon  the  typhoid  bacillus,  and  it  is  not 
intended  to  here  discuss  the  subject  of  the  effect  of  the  artificial 
addition  of  inorganic  elements  or  compounds,  such  as  copper 
sulphate,  for  the  destruction  of  bacteria. 

The  oxygen  content  of  a  given  water  containing  typhoid  bacilli 
is  undoubtedly  a  factor  of  the  greatest  importance  in  relation  to 

^  Hill:  Boston  Medical  and  Surgical  Journal,  1901,  CXLV,  557. 
*  Sedgwick:  "Sanitary  Science,"  1905. 


APPENDIX  X.  353 

the  viability  of  these  organisms,  but  it  has  as  yet  received  but 
little  attention. 

Whipple  and  Mayer  ^  have,  however,  clearly  shown  that  the 
absence  of  dissolved  oxygen  has  a  most  decided  and  rapid  detri- 
mental effect  upon  typhoid  bacilli  in  both  water  and  bouillon. 
They  question  whether  this  fact  has  been  given  the  consideration 
which  it  deserves  in  the  interpretation  of  the  results  of  laboratory 
experiments  upon  the  viability  of  this  organism.  Experiments 
in  which  small  amounts  of  water,  sewage  or  bouillon,  sterilized 
by  heat,  are  utilized  should  certainly  take  into  consideration  the 
question  of  the  lack  of  oxygen  in  such  liquids.  The  difference 
in  resistance  of  the  typhoid  bacillus  in  soils  and  in  liquids  under 
apparently  similar  physical  conditions,  as  already  noted,  may 
possibly  be  due  to  a  greater  amount  of  oxygen  in  the  soils  than 
in  the  liquids. 

This  conception  of  Whipple  and  Mayer  is  of  the  greatest 
importance,  as  it  involves  the  question  of  the  effect  of  the  almost 
total  lack  of  oxygen  in  the  effluent  of  septic  tanks  upon  the 
typhoid  bacilli  which  are  present  in  most  raw  sewages.  If 
typhoid  bacilli  cannot  exist  for  more  than  one  or  two  days  in  the 
septic  tank  it  is  a  fact  of  the  utmost  importance. 

The  relation  between  the  presence  of  organic  matter  in  water 
and  the  viability  of  the  typhoid  bacillus  is  likewise  an  important 
matter. 

In  the  early  days  of  bacteriology  Bolton  showed  that  in  water 
repeatedly  redistilled  and  inoculated  with  typhoid  bacilli,  so  as 
to  avoid  introducing  organic  matter,  the  typhoid  organisms  died 
out  rapidly. 

Wheeler^  also  shows  that  the  less  organic  matter  present  in 
water  the  less  favorable  the  influence  upon  the  viability  of  the 
typhoid  bacillus. 

By  far  the  most  extensive  and  valuable  series  of  tests  made 
upon  this  phase  of  the  subject  were  those  of  Jordan,  Russell  and 

'  Whipple  and  Mayer:  Journal  of  Infectious  Diseases,  1906,  Supple- 
ment II,  p.  76. 

^  Wheeler:  Loc.  Cit. 


354  TYPHOID  FEVER. 

Zeit,^  and  later  of  Russell  and  Fuller.^  They  tested  the  effect 
of  natural  conditions,  excluding  sunlight,  upon  celloidin,  agar  or 
parchment  capsules,  to  which  typhoid  bacilli  placed  in  various 
relatively  unpolluted  and  polluted  waters  and  sewage  were  like- 
wise added,  and  in  which  also  the  capsules  were  then  floated. 

All  possible  grades  and  combinations  from  relatively  pure 
waters  to  sewage  inside  these  permeable  sacs  to  sewage  and  rela- 
tively pure  waters  outside  of  them,  and  varying  conditions  from 
those  done  in  nature  to  those  in  the  laboratory  were  utilized  in 
these  tests. 

The  authors  conclude  that  in  relatively  pure  waters,  of  a  surface 
character,  the  typhoid  bacillus  is  capable  of  retaining  its  vitality 
for  about  eight  days. 

When  the  typhoid  bacillus  was  inoculated  into  sewage  it  com- 
pletely disappeared  in  five  days,  and  even  in  two  or  three  days 
the  majority  of  the  organisms  were  killed  off.  They  believe, 
therefore,  that  the  typhoid  organism  in  natural  sewage  does  not 
live  as  long  as  it  will  in  relatively  pure  water. 

They  believe  that  the  activity  of  the  saprophytic  bacteria  in 
the  sewage  and  polluted  water  plays  a  considerable  role  in  this 
rapid  destruction  of  the  typhoid  organism.  However,  the  most 
convincing  work  on  this  aspect  of  the  subject  has  been  done  by 
Frost,^  working  with  a  similar  technique  of  celloidin  sac  contain- 
ing typhoid-inoculated  fluids,  with  growths  of  saprophytic  bac- 
teria in  the  water,  and  bouillon  in  which  the  sacs  are  placed. 

The  saprophytic  bacteria  he  used  were  obtained  from  garden 
earth,  street  dust,  sand  and  various  waters.  In  many  tests  the 
soils  themselves  were  inoculated  into  liquid  surrounding  the  sacs. 

Frost  found  that  the  typhoid  bacilli  were  rapidly  killed  in  these 
sacs  by  thermostabile  products  of  the  growth  of  certain  soil  bac- 
teria (B.  vulgatus,  B.  vulgaris.  Pa.  fluorescens  and  Pa.  putida), 
which  acted  best  at  body  temperature,  but  which  were  appar- 

*  Jordan,  Russell  and  Zeit:  Loc.  Cit. 

^  Russell  and  Fuller:  Journal  of  Infectious  Diseases,  1906,  Supplement 
II,  p.  40. 

^  Frost:  Journal  of  Infectious  Diseases,  1904,  I,  599. 


APPENDIX  X.  355 

ently  uninfluenced  by  other  conditions.  They  operate,  however, 
only  when  these  bacteria  are  grown  with  or  slightly  in  ad- 
vance of  the  typhoid  bacillus.  These  thermostabile  substances 
undoubtedly,  therefore,  play  directly  a  large  part  in  the  .destruc- 
tion of  typhoid  bacilli  in  water  and  sewage  under  natural  con- 
ditions. 

Frost  was  unable  to  explain  their  very  feeble  action  at  low 
temperatures;  nor  is  there  any  explanation  as  yet  offered  as  to 
why  they  do  not  act  more  promptly  on  typhoid  bacilli  in  soils. 
It  may  be  possible  that  they  operate  more  strongly  in  the  absence 
of  oxygen.     Frost  was  not  specially  clear  on  this  point. 

Wheeler  ^  found  a  harmless  saprophytic  bacillus  carrotoverus 
which  actually  stimuilated  the  development  of  the  typhoid  bacillus 
when  sown  with  it. 

Huntemiiller  ^  has  shown  that  various  low  forms  of  protozoa 
are  capable  of  feeding  upon  typhoid  bacilli. 

Klein  ^  has  shown  that  normal  oysters,  clams  and  other  shell- 
fish, when  grown  in  unpolluted  waters,  do  not  contain  bacillus 
coli  or  sewage  bacteria  in  their  intestinal  canals,  but  that  when 
placed  in  sewage-polluted  waters  they  become  badly  contaminated 
by  such  organisms.  However,  if  they  are  removed  from  such 
polluted  waters  and  kept  under  favorable  conditions,  they  have 
the  power  of  freeing  themselves  from  both  these  colon  and 
typhoid  bacilli  previously  taken  in.  The  rate  at  which  this  is 
accomplished  depends  upon  the  severity  of  the  pollution. 

^  Wheeler:  Loc.  Cit. 

'  Huntemuller:  Archiv  fur  Hygiene,  1905,  LIV,  89. 

'  Klein:  Lancet,  1905,  Vol.  168,  p.  1133. 


APPENDIX  XI. 

TYPHOID   FEVER   IN   UNITED    STATES  ARMY  CAMPS. 

{From  the  Report  on  the  Origin  and  Spread  of  Typhoid  Fever  in  the 
United  States  Military  Camps  during  the  Spanish  War  of  i8q8, 
by  Dr.  Walter  Reed,  Dr.  Victor  C.  Vaughan  ajid  Dr.  Edward  O. 
Shakespeare. ) 

General  Statements  and  Conclusions. 

1.  During  the  Spanish  War  of  1898  every  regiment  constituting 
the  First,  Second,  Third,  Fourth,  Fifth  and  Seventh  Army  Corps 
developed  typhoid  fever. 

2.  More  than  90  per  cent  of  the  volunteer  regiments  developed 
'typhoid  fever  within  eight  v^^eeks  after  going  into  camp. 

3.  Typhoid  fever  developed  also  in  certain  of  the  regular  regi- 
ments within  three  to  five  weeks  after  going  into  camp. 

4.  Typhoid  fever  became  epidemic  both  in  the  small  encamp- 
ments of  not  more  than  one  regiment,  and  in  the  larger  ones  consist- 
ing of  one  or  more  corps. 

5.  Typhoid  fever  became  epidemic  in  camps  located  in  the  North- 
em  as  well  as  in  those  located  in  the  Southern  States. 

6.  Typhoid  fever  is  so  widely  distributed  in  this  country  that  one 
or  more  cases  are  likely  to  appear  in  any  regiment  within  eight  weeks 
after  assembly. 

7.  Typhoid  fever  usually  appears  in  military  expeditions  within 
eight  weeks  after  assembly. 

8.  The  miasmatic  theory  of  the  origin  of  typhoid  fever  is  not 
supported  by  our  investigations. 

9.  The  pythogenic  theory  of  the  origin  of  typhoid  fever  is  not 
supported  by  our  investigations. 

10.  Our  investigations  confirm  the  doctrine  of  the  specific  origin 
01  typhoid  fever. 

356 


APPENDIX  XI.  357 

11.  With  typhoid  fever  as  widely  disseminated  as  it  is  in  this 
country,  the  chances  are  that  if  a  regiment  of  1300  men  should  be 
assembled  in  any  section  and  kept  in  a  camp  the  sanitary  conditions 
of  which  were  perfect,  one  or  more  cases  of  typhoid  fever  would 
develop. 

12.  Typhoid  fever  is  disseminated  by  the  transference  of  the 
excretions  of  an  infected  individual  to  the  alimentary  canals  of  others. 

13.  Typhoid  fever  is  more  likely  to  become  epidemic  in  camps 
than  in  civil  life  because  of  the  greater  difl&culty  of  disposing  of  the 
excretions  from  the  human  body. 

14.  A  man  infected  with  typhoid  fever  may  scatter  the  infection 
in  every  latrine  in  a  regiment  before  the  disease  is  recognized  in 
himself. 

15.  Camp  pollution  was  the  greatest  sin  committed  by  the  troops 
in  1898. 

16.  Some  commands  were  unwisely  located. 

17.  In  some  instances  the  space  allotted  the  regiments  was  in- 
adequate. 

18.  Many  commands  were  allowed  to  remain  on  one  site  too  long. 

19.  Requests  for  change  in  location  made  by  medical  officers  were 
not  always  granted. 

20.  Superior  line  officers  can  not  be  held  blameless  for  the  unsani- 
tary condition  of  the  camps. 

21.  Greater  authority  should  be  given  medical  officers  in  questions 
relating  to  the  hygiene  of  camps. 

22.  It  may  be  stated  in  a  general  way  that  the  number  of  cases  of 
typhoid  fever  in  the  different  camps  varied  with  the  methods  of 
disposing  of  the  excretions. 

23.  The  tub  system  of  disposal  of  fecal  matter  as  practiced  in  the 
Second  Division  of  the  Seventh  Army  Corps  is  to  be  condemned. 

24.  The  regulation  pit  system  is  not  a  satisfactory  method  of 
disposing  of  fecal  matter  in  permanent  camps. 

25.  In  permanent  camps,  where  water  carriage  cannot  be  secured, 
all  fecal  matter  should  be  disinfected  and  then  carted  away  from  the 
camp. 

26.  Infected  water  was  not  an  important  factor  in  the  spread  of 
typhoid  fever  in  the  national  encampments  in  1898. 


358  TYPHOID  FEVER. 

27.  To  guard  against  the  contamination  of  the  water  supply,  troops 
in  the  field  should  be  provided  with  means  for  the  sterilization  of 
water. 

28.  Flies  undoubtedly  served  as  carriers  of  the  infection. 

29.  It  is  more  than  likely  that  men  transported  infected  material 
on  their  persons  or  in  their  clothing  and  thus  disseminated  the 
disease. 

30.  Typhoid  fever,  as  it  developed  in  the  regimental  organizations, 
was  characterized  by  a  series  of  company  epidemics,  each  one  having 
more  or  less  perfectly  its  own  individual  characteristics. 

31.  It  is  probable  that  the  infection  was  disseminated  to  some 
extent  through  the  air  in  the  form  of  dust. 

32.  A  command  badly  infected  with  typhoid  fever  does  not  lose 
the  infection  by  simply  changing  location. 

^^.  When  a  command  badly  infected  with  typhoid  fever  changes 
its  location  it  carries  the  specific  agent  of  the  disease  in  the  bodies  of 
the  men,  in  their  clothing,  bedding,  and  tentage. 
■  34.  Even  an  ocean  voyage  does  not  relieve  an  infected  command 
of  its  infection. 

35.  After  a  command  becomes  badly  infected  with  typhoid  fever, 
changes  of  location,  together  with  thorough  disinfection  of  all  cloth- 
ing, bedding,  and  tentage  is  necessary. 

36.  Except  in  case  of  the  most  urgent  military  necessity  one 
command  should  not  be  located  upon  the  site  recently  vacated  by 
another. 

37.  The  fact  that  a  command  expects  to  change  its  location  does 
not  justify  neglect  of  proper  policing  of  the  ground  occupied. 

38.  It  is  desirable  that  the  soldier's  bed  should  be  raised  from  the 
ground. 

39.  In  some  of  the  encampments  the  tents  were  too  much  crowded. 

40.  Medical  officers  should  insist  that  soldiers  remove  their  outer 
clothing  at  night  when  the  exigencies  of  the  situation  permit. 

41.  Malaria  was  not  a  prevalent  disease  among  the  troops  that 
remained  in  the  United  States. 

42.  The  continued  fever  that  prevailed  among  the  soldiers  in  this 
country  in  1898  was  typhoid  fever. 

43.  In  addition  to  the  recognized  cases  of  typhoid  fever,  there 


APPENDIX  XI.  359 

were  many  short  or  abortive  attacks  of  this  disease  which  were 
generally  diagnosed  as  some  form  of  malarial  fever. 

44.  While  our  examinations  show  that  coincident  infection  with 
malaria  and  typhoid  fever  may  occur,  the  resulting  complex  of 
symptoms  are  not  sufficientiy  well  defined  and  uniform  to  be  recog- 
nized as  a  separate  disease. 

45.  About  one-fifth  of  the  soldiers  in  the  national  encampments 
in  the  United  States  in  1898  developed  typhoid  fever. 

46.  Army  surgeons  correctly  diagnosed  about  half  the  cases  of 
typhoid  fever. 

47.  The  percentage  of  death  among  cases  of  typhoid  fever  was  7.61. 

48.  When  a  command  is  thoroughly  saturated  with  typhoid  fever 
it  is  probable  that  one-fourth  to  one-third  of  the  men  will  be  found 
susceptible  to  this  disease. 

49.  In  military  practice  typhoid  fever  is  often  apparently  an 
intermittent  disease. 

50.  The  behef  that  errors  in  diet  with  consequent  gastric  and 
intestinal  catarrh  induce  typhoid  fever  is  not  supported  by  our 
investigation. 

51.  The  behef  that  simple  gastro-intestinal  disturbances  predis- 
pose to  typhoid  fever  is  not  supported  by  our  investigation. 

52.  In  a  considerable  per  cent  (a  httle  more  than  one-third)  of 
the  cases  of  typhoid  fever  which  are  recorded  as  having  been  preceded 
by  some  intestinal  disturbance,  the  preceding  illness  was  so  closely 
followed  by  typhoid  fever  that  we  must  regard  the  former  as  having 
occurred  within  the  period  of  incubation  of  the  latter. 

53.  More  than  90  per  cent  of  the  men  who  developed  typhoid 
fever  had  no  preceding  intestinal  disorder. 

54.  The  deaths  from  typhoid  fever  were  86.24  per  cent  of  the 
total  deaths. 

55.  The  morbidity  from  typhoid  fever  per  1000  of  mean  strength 
was  a  httle  less  than  one-fifth  (192.65). 

56.  The  mortahty  from  typhoid  fever  per  1000  of  mean  strength 
was  14.63. 

57.  The  average  period  of  incubation  in  typhoid  fever  is  probably 
about  ten  and  a  half  days. 

The  following  table  contains  data  illustrating  these  points: 


36o 


TYPHOID  FEVER. 


■sssea 

-sia  HTB  raoi;  sqjBaa 

oj  pioqdAx  niojj 

00  00  00  00  00         00 

On  O^ 
m  M 

NO     PI 

00  00 

p) 

•sasBa 

t^  g\  N  onoo        w 

OVO    M   in'O        oo 
ro  •*  H    (N    H         <N 

00  2^ 

M 

M 

'AnBjBj  JO  aSBjnaoja,! 

T|-  CO  O    c^    t>.        O 
in  ovd   CMn       O 

O  00 
in  PI 

t^  On 

o 

NO 

•ooo'ooi 
13(1  ajB^  iljipiqjoji 

in  0\  "+00  t^       O 
N   r^  m  rOMO         ro 
O    -^J-  On  "    M           O 
M   M   c>  H   d^        in 

M      CT      H      H      H              P) 

On  O 

C>NO 

NO 
PI 

•ooo'ooi 

On  t^  t^  O   "^        in 
M   cs    H   r^  r^        0 
n    0    PO  O   O         fO 

M      «       M      M      M                C^ 

NO    o 

■5j-  in 

M      M 

NO 

■* 

•jaAa^ 
pioqd^x  nioj}  sqjBaa 

Tj- 1^  a\  M  o      oo 

Tj-  M    On  M   m        ■Ti- 
ro ■*         MM          M 

o  o 

NO     PI 

o 

00 

in 

•3]qBqojd  puB  otBjJ33 
'jaA9j[  pioqdix  Jo  S3SB3 

H  00  00  NO    O          ro 
P)    M    On  <N    0^          On 
On  ^  -^  <N  NO         NO 
in  "J?  h"  n"  pT         ct" 

NO     PI 

•*   On 

t  "., 

d^  M 

M 

00 

o" 

•qilSnajJs  rnssjfi 

0  00    t^  t^  (N          0^ 
00  NO    O    O  NO          lo 

ro  in  inoq^  on       t;- 
rC  o"  rC  o^  ro        O 

PI      0^               MM               M 

po  o 

00    On 
On  On 

m 

o> 

tc 

o 

M 

•sjnamiSa^  jo  jaqnin^ 

PI    r^  t^OO    PI           o^ 

PI      M              MP! 

in  t^ 

00 

PI 

On 

1 

•a 

a 

o 
O 

First  Army  Corps  (Chickamauga) 
Third  Army  Corps  (Chickamauga) 
Fourth  Army  Corps  (Tampa)     .    . 
Second  Army  Corps  (Alger)    .    .    . 
Second  Army  Corps  (Meade)      .    . 
Seventh  Army  Corps,  Second  Divi- 
sion (Jacksonville) 

C 

o 
•55 

V 
Q 
•H 

H 
uT 

Oh 

u 
o 
U 
>% 

S 
< 

> 
<u 

-o 
c 

1- 
C 

APPENDIX   XII. 

EXTRACT    FROM    THE    PRESIDENTIAL    MESSAGE 
OF    THEODORE    ROOSEVELT,  DECEMBER,  1907. 

L.AJiGER  Medical  Corps  Needed. 

The  Medical  Corps  should  be  much  larger  than  the  needs  of  our 
Regular  Army  in  war.  Yet  at  present  it  is  smaller  than  the  needs 
of  the  service  demand  even  in  peace.  The  Spanish  War  occurred 
less  than  ten  years  ago.  The  chief  loss  we  suffered  in  it  was  by 
disease  among  the  regiments  which  never  left  the  coimtry.  At  the 
moment  the  nation  seemed  deeply  impressed  by  this  fact;  yet  seem- 
ingly it  has  already  been  forgotten,  for  not  the  slightest  effort  has 
been  made  to  prepare  a  medical  corps  of  sufficient  size  to  prevent 
the  repetition  of  the  same  disaster  on  a  much  larger  scale  if  we  should 
ever  be  engaged  in  a  serious  conflict. 

The  trouble  in  the  Spanish  War  was  not  with  the  then  existing 
officials  of  the  War  Department;  it  was  wath  the  representatives  of 
the  people  as  a  whole  who,  for  the  preceding  thirty  years,  had  declined 
to  make  the  necessary  provision  for  the  army.  Unless  ample  pro- 
N^ision  is  now  made  by  Congress  to  put  the  Medical  Corps  where  it 
should  be  put,  disaster  in  the  next  war  is  inevitable,  and  the  respon- 
sibility will  not  lie  with  those  then  in  charge  of  the  War  Depart- 
ment, but  with  those  who  now  decline  to  make  the  necessary  pro- 
\'ision.  A  well -organized  medical  corps,  thoroughly  trained  before 
the  advent  of  war  in  all  the  important  administrative  duties  of  a 
military  sanitar}^  corps,  is  essential  to  the  efficiency  of  any  large 
army,  and  especially  of  a  large  volunteer  army. 

Such  knowledge  of  medicine  and  surgery  as  is  possessed  by  the 
medical  profession  generally  will  not  alone  suffice  to  make  an  efficient 
military  surgeon.  He  must  have,  in  addition,  knowledge  of  the 
administration  and  sanitation  of  large  field  hospitals  and  camps,  in 
order  to  safeguard  the  health  and  Hves  of  men  intrusted  in  great 
numbers  to  his  care.  A  bill  has  long  been  pending  before  the  Con- 
gress for  the  reorganization  of  the  Medical  Corps;  its  passage  is 
urgently  needed. 

361 


APPENDIX   XIII. 

MEDICINE    IN    PEACE    AND    WAR. 

By  Dr.  Louis  Livingston  Seaman,  New  York. 
{From  the  New  York  Medical  Journal,  February  22,  1908.) 

The  splendid  achievements  of  scientific  medicine  in  civil 
life  in  the  prevention  of  disease  should  be  even  more  effectually 
obtained  in  the  army,  where  only  healthy  men  are  accepted,  and 
vigorous  outdoor  camp  life  should  keep  its  units,  who  are  sub- 
ject to  strict  military  discipline,  in  perfect  physical  condition. 
Health  alone,  however,  is  no  guarantee  against  the  insidious 
attack  of  the  silent  foe  that  lingers  in  every  camp  and  bivouac. 
It  is  this  foe,  as  the  records  of  wars  for  the  past  200  years  have 
proved,  that  is  responsible  for  four  times  as  many  deaths  as  the 
guns  of  the  enemy,  to  say  nothing  of  the  vast  number  tempora- 
rily invalided  or  discharged  as  unfit  for  duty.  It  is  this  dread- 
ful unnecessary  sacrifice  of  life  from  preventable  disease  that 
constitutes  the  hell  of  war. 

Unless  an  army  maintains  a  thoroughly  organized  sanitary 
corps,  prepared  to  fight  germs  and  diseases  in  advance  of  the 
fighting  forces,  testing  the  water  supplies,  and  avoiding  the 
dangers  from  contagion  and  infection,  the  medical  depart- 
ment might  as  well  be  abolished.  If  the  Japanese  had  not 
realized  this  before  their  last  war  and  taken  measures  to  pre- 
vent disease,  their  army  would  never  have  won  their  brilliant 
and  uninterrupted  series  of  victories.  If  they  had  sustained 
the  same  ratio  of  mortality  from  sickness  as  in  their  war  with 
China  ten  years  before,  their  losses  from  disease  alone  in  the 

362 


APPENDIX  XIII.  363 

Russian  war  would  have  nearly  equaled  the  total  of  their  entire 
losses  from  all  causes.  This  proves  the  value  of  the  medical 
and  sanitary  corps,  and  illustrates  its  importance  as  a  factor 
in  the  winning  of  the  final  issue. 

The  days  of  operative  surgery  on  the  field  of  battle  or  at  the 
front  passed  with  the  discovery  of  asepsis  and  antisepsis.  The 
Russo-Japanese  war  taught  many  lessons  and  destroyed  many 
ideals  in  matters  military  as  in  matters  surgical,  where  the 
hitherto  accepted  idea  of  the  duties  of  the  military  surgeon  was 
shown  to  be  erroneous,  where  asepsis  and  antisepsis  relegated 
the  use  of  the  scalpel  to  comparative  obscurity  and  demonstrated 
conclusively  that  preser\'ation  of  the  army  by  prevention  of 
disease  is  the  surgeon's  duty,  first,  last,  and  nearly  all  the  time. 
In  surgical  technique,  or  in  the  after  treatment  of  the  wounded 
and  sick,  the  Japanese  taught  the  foreigner  comparatively 
little,  but  in  the  field  of  sanitary  science  and  dietetics  they 
demonstrated  what  had  never  been  done  before,  viz.,  that 
preventable  diseases  are  preventable  and  can  be  controlled; 
and  that  the  great  incubus  of  an  army  in  the  field,  the  presence 
of  crowded  hospitals  and  the  large  and  expensive  force  neces- 
sary to  equip  and  conduct  them,  can  to  a  large  extent  be 
eliminated. 


The  Medical  Department  of  our  army,  whose  archaic 
system  almost  parallels  that  of  Peking,  while  falling  far  below 
that  of  Patagonia  (and  I  am  familiar  with  both  and  speak 
advisedly),  although  unequal  to  cope  with  the  exigencies  of  the 
Spanish  campaign,  is  to-day,  as  the  Surgeon  General  states, 
relatively  50  per  cent  worse  off  in  numbers  than  at  the  close 
of  the  CivU  War  in  1864,  or  at  the  termination  of  the  Spanish- 
American  campaign.  The  theory  upon  which  it  is  founded 
that  the  cure  of  disease  rather  than  its  prevention  is  its  objective, 
still  renuLtns  in  vogue.     Although  men  of  brilliant  attainments 


364  TYPHOID   FEVER. 

and  individual  merit  are  found  on  its  staff,  the  deplorable 
system  under  which  they  are  compelled  to  serve,  and  their  lack 
of  authority  to  enforce  sanitation  and  hygiene,  render  the 
advisability  of  the  continuance  of  the  department  under 
present  conditions  problematical. 

Under  the  present  system,  the  same  old  medical  regulations 
remain  in  vogue  to  all  intents  and  purposes  as  prevailed  before 
the  microbic  origin  of  disease  was  discovered  and  the  key  to 
sanitation  found.  So  that,  if  another  war  were  to  be  declared 
next  summer,  our  government  would  again  convert  the  units 
of  its  army  into  hospital  patients,  and  its  veterans  into  pen- 
sioners. 

Under  the  present  system  the  line  officer  of  the  army  is 
imder  no  obligation  to  accept  the  recommendation  of  the 
medical  officer  as  to  the  site  or  sanitation  of  a  camp.  Even  in 
time  of  peace,  he  has  no  executive  power  to  enforce  sanitation, 
although  he  may  be  convinced  that  the  health  of  every  man 
is  being  jeopardized. 

The  officers  of  artillery,  of  cavalry,  of  infantry,  the  engi- 
neers, and  of  the  signal  service,  can  compel  obedience  to  their 
orders,  but  the  medical  man,  whose  department  fights  the  foe 
that  has  killed  80  per  cent  in  the  majority  of  the  great  wars  of 
history,  cannot  enforce  an  order,  but  can  only  make  a  recom- 
mendation, which  the  line  officer  can  accept  or  reject  at  his 
discretion. 

The  importance  of  the  medical,  as  compared  with  the  other 
staff  departments,  has  never  been  recognized  or  appreciated. 
Until  it  is  realized  that  the  most  important  function  of  the 


APPENDIX  XIII.  365 

medical  officer  is  in  the  prevention  of  disease  rather  than  its 
cure,  the  old  custom  will  prevail.  To  be  efficient  the  medical 
officer  must  not  only  be  a  good  physician,  but  a  sanitarian, 
a  bacteriologist,  often  a  chemist  as  well  as  an  administrator. 
Upon  him  devolves  the  duty  of  preventing  disease,  and  his 
part  in  maintaining  the  effectiveness  of  the  units  makes  him 
an  important  factor  in  the  military  establishment.  His  status 
is  essentially  military,  not  in  the  sense  of  holding  command, 
but  as  an  integral  part  of  an  organization,  complex  in  its  com- 
position, and  whose  different  members  should  be  so  organized 
as  to  produce  a  harmonious  and  effective  whole.  Under  the 
existing  system,  he  is  looked  upon  simply  as  a  doctor,  whose 
sole  function  is  treating  the  sick  and  wounded  —  whose  duties 
should  be  confined  to  the  hospital,  and  whose  recommendations 
should  be  submitted  only  when  asked  for. 

The  entire  appropriation  of  the  Medical  Department  for  the 
fiscal  year  of  1898  was  less  than  $1,000,000;  this  was  increased 
at  the  outbreak  of  hostilities  with  Spain  by  something  over 
$2,000,000.  Then  came  the  war.  As  a  result  of  that  almost 
bloodless  conflict,  the  actual  hostilities  of  which  lasted  only 
less  than  six  weeks,  we  paid  last  year  alone  $3,471,157  in 
pensions,  with  the  further  assurance  of  an  annual  increase  for 
many  years  to  come.  The  rolls  of  the  Pension  Office  to-day 
bear  the  names  of  24,000  pensioners,  over  19,000  of  whom  are 
invalids  and  survivors  of  this  war,  and  over  18,000  additional 
claims  are  now  pending;  although  the  total  of  the  Cuban  army 
of  invasion  was  only  20,000  men. 

Let  us  hope  that  the  day  is  not  distant  when  the  true  value 
of  the  medical  man  in  war  will  be  appreciated  in  our  own  land 
and  he  will  be  given  the  authority  in  his  own  sphere  that  will 
make  it  possible  for  our  army  in  the  day  of  emergency  to  equal, 


366  TYPHOID  FEVER. 

if  not  surpass,  this  splendid  record.  Braver  men  never  served 
with  the  colors  than  the  American  soldiers,  as  we  proved  on 
both  sides  of  the  Civil  War,  where  many  battles  (in  one  of  which, 
at  Cold  Harbor,  ten  thousand  men  fell  in  ten  minutes)  exceed- 
ing anything  known  in  the  Orient,  and  where  it  was  con- 
clusively proved  that  our  soldier  deserves  every  care  and  pro- 
tection a  generous  government  can  bestow. 

«f«  «i«  ^  ^  *lc  ^  ik 


APPENDIX  XIV. 
DATA  AS  TO    COST   OF  TYPHOID   FEVER. 

The  following  data  are  taken  from  the  Engineering  News, 
of  March  5,  1908,  in  which  quotations  are  given  from  a  report 
by  Mr.  Frank  E.  Wing,  Associate  Director  of  the  Pittsburg 
Survey,  being  part  of  a  sociological  study  carried  on  by  the 
magazine  "  Charities  and  Commons  of  New  York,  by  means  of 
an  appropriation  from  the  Sage  Foundation." 

A  study  was  made  of  the  typhoid  fever  cases  in  Wards  8  and 
II,  of  Pittsburg,  Pa.  Of  the  433  cases  that  occurred  in  these 
wards  during  the  year  ending  June  30,  1907,  data  were  secured 
concerning  194.      The  data  obtained  are  very  instructive  : 

Number  of  families  in  which  typhoid  fever  cases  occurred.  ...  149 

Number  of  individuals  in  these  families 999 

Number  of  persons  taken  with  typhoid  fever  during  one  year  194 

Number  of  deaths  from  typhoid  fever 11 

Number  of  children  taken  with  typhoid 89 

Number  of  wage  earners 87 

Number  of  weeks'  work  lost  by  these  wage  earners 964 

Loss  of  wages ^10,902 

Loss  of  time  by  other  wage  earners  caring  for  patients,  weeks  182 

Loss  of  wages  by  these  caretakers ^ii5S7 

Number  of  C5,ses  treated  in  hospitals 53 

Hospital  costs  paid  by  patients ;^i,i4i 

Hospital  costs  paid  by  charity ^1,534 

Doctors'  and  nurses'  bills,  medicines,  etc.,  of  patients  treated  at 

home ^8, 1 79 

Funeral  expenses  of  six  patients  who  died $1,032 

Total  cost $24,359 

Fatality  of  the  disease 5-7% 

Cost  of  typhoid  fever  per  patient $^25 

Cost  of  typhoid  fever  per  typhoid  death $2,200 

367 


APPENDIX   XV. 
TYPHOID  FEVER  LITERATURE. 

The  literature  of  typhoid  fever  and  its  allied  subjects  is  so 
enormous  that  to  do  it  even  scant  justice  would  too  greatly 
extend  the  limits  of  the  present  work,  while  any  list  of  references 
that  might  be  given  as  complete  to-day  would  be  incomplete 
to-morrow,  so  rapidly  is  the  subject  being  developed.  It  is 
assumed  therefore  that  those  interested  in  the  medical  aspects 
of  typhoid  fever  in  its  bacteriology,  in  water  analysis  and 
water  filtration,  in  sewage  purification,  in  milk  pasteurization, 
and  in  the  general  engineering  and  sanitary  matters  involved 
;in  the  prevention  of  the  disease,  will  seek  their  information  from 
the  many  published  works  on  those  topics. 

For  the  benefit  of  students,  however,  a  few  references  to 
reports  and  monographs  descriptive  of  certain  typhoid  fever 
epidemics  are  given  below.  Descriptions  of  many  other  epi- 
demics may  be  found  in  the  files  of  the  medical  and  engineering 
journals,  in  the  annual  reports  of  va,rious  state  boards  of  health 
and  the  local  boards  of  health  of  cities  and  towns  and  in  the 
publications  of  the  U.  S.  Governmental  departments. 


368 


APPENDIX   XV. 


369 


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^        ^        P^ 


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i3  o- 


PQ  C/J  C/^  CAl         COI 


tn     IH     1-1     1-1 


tH      IH      >-l      IH      l-l      h 


il)(D<D(U  (L)(U<LtaJlC)(U 


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370 


TYPHOID    FEVER. 


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APPENDIX  XV. 


371 


■73  *^    0 

-5  C  . «  ii 
b  •  O  d  <u 
So—      ^ 

a,^  S  ij  3    . 
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<      ^- 


a, 


10     t^     4.=  '^  ^  ii  f^  "   - 

o       ^  en    .r^kSj.sc-'^'^ 


^>^3rSbb-S,j5ffi^gy 


fo  aJ 


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WK 


M      P^ 


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•  TD 

d     ; 

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•  s 

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3    U 
nj    CI, 

►^   tn 

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•  5  ■& 

1- 

Pi       <?.Pi 


u 


so 


uu 


00  O    -:f 

Os  On         On  O 


in 

(U 


J3U 


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1.       "^ 


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372 


TYPHOID   FEVER. 


O 
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h 
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h 

hH 

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w 

w 

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P^ 
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O) 

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ChCO 

^H 

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p; 
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H 

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p-g 

o 
o 

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On  O     N     0     H 

t^  On  IH  NO    CO 

C    8 
^1 

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00    rC  M    -^  M 

M 

H   00     >0    H     ^ 

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CO  t^NO    t^  o 
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4 
o 

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IH 

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t^  lO  CO  0 

rO     ■    w    O    IN 

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oj    0    u-)  01   t^ 
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CO  t^  t^  0)       ■ 

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3  -^ 

p:5« 

0 

a 

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00   t^  0   r^  m' 

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li-j  CO  On  ^    CS 
01    ro  M  NO    O 

oo  O    ro  t^NO 
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NO      Tl-    TJ-NO         • 
00   Tl- 

ct 

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IH    2 

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On  M    lO  ■*  O 

ro  M     04     CS    4^ 

NO     M     O     0)     w 
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NO     CO  lO  On  ■* 
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si 

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NO    oo  oo  OnOO 

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CO  CO        01    01 

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CCS    G-a 

c  c  c  cxt; 

APPENDIX  XVI. 


373 


0\  N 

IT)           <C^ 

ro 

00 

t^              CO 

ir>      vo 

f^ 

CO    lO     • 

\0       .     ■+  N       . 

0 

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H        •     W 

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On  ■* 

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00     CKVO  00 

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lO  rooo    t^oo 

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t^OO 

00    t^  Ul  t^  !>. 

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00  00    rj-  H 

o 

00     CO  J^OO     <N 

\0  'O   o 

ro  On 

00 

MOOrOOOv        ■^fOiO'* 


CO  ■LTi  Tj-  rn  ri-        MM  looo    Ti- 


•*  Tt^O    lO  On 


Tj-  fO^O   J^ro 

1^  J:^  O    H   lO 

M   PC  rooO   U-) 

POOO    PO  PO  ^ 

O 

O   vo  PI  00 

O 

On  NO  00    ■*  lO 
■<i-NO    fO  P)    N 

<N    lO  lO  "*   O 

ro  M    ro  -^  M 

On  PI    '^  O    O 

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l^NO   looo    O 
r^  M    PD  ro  PI 

«  o 

M      PI 

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NO 
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M 

CO  OnOO    tI-  Tt- 

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ir>  t^  P)  NO  00 

w  00    O    P)  00 

i^ 

PI     M 

On  t^ 

00 

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O    On  N    1/^  ro 

vo  PO  ■*  ro  -^ 

CO  ^NO  T^  o 

w    H    PO  «    On 

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NO 

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M 

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CO  00    t^  0   lO 

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NO 

PI    roNO    M 
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o 

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PI     CO  PI     PI    lO 


M  NO    Ti-   PI     PI 

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lO 


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PO  i^  t^  O  00 

00     -*  lO  lO  Tj- 

NO     M     OnOO     Tf 

M  Tt  oo"  i-Too" 


r^  POOO   PI   PI 

t^NO      PI      PI      M 
■^  VONO    f^  On 


t^nO  no  no    _,. 
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■*  -^No^oo^^sg 
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MM  ^•' 


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rS  -S^  o  bo  60     5 

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374 


TYPHOID  FEVER. 


u 


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to    •  t^ 

iii 

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ro  O    IN    OnOO 

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to    ■    -* 

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to  O    O    '^t     " 

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00    rONO    ro  c^^ 

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UUL 

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APPENDIX   XVI. 


375 


N    O  f^^ 

M     On 

U-)  CO 

01  O 

r^ 

^O 

00 

O  •  ^  «  '* 

t^   .  IT)   • 

CO   •  CO   •   • 

CO  01 

NO   01 

r^  -  . 

CO  ■   ■ 

1-1  t^ 

NO 

CNOO  0  PO  ro 

M  loOO  00  00 

t^ 

W  M  Tj-  to 

NO  M 

r^  CO  t^ 

M  O  conO  O 

to 

■^  ifi  -^  vn  \j^ 

H  ■*  lO  •*  -* 

ir>  On  On  no  lo 

00    c<  w  -^ 

lyr*  lO  M  o 

W  ■*  M  C<  CS 

O   H 

'^  01 

■*  r^  'i- 

'^l-  01  ^ 

NO  nO  00 

o<  00 
lo  01 

On 

\0  CO  O  fO  u-3 

r^  t^  O  01  t^ 

w 

l/^  -I-  COOO 

CO  NO 

TfNO  •+ 

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On 

On  O  ^  N  PO 

•?t-  ro  O  N  0 

t^  On  •*  On  O. 
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lO 

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0  t^ 

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Tj-  in 

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cOnO  t--  '^ 

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lO  W  lO  •*  lO 

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lo  0 
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too 
to  00 

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to  fO  01  0  00 

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01  Ci  Tj-  l-l 

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NO  NO  r^NO  NO 

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to 

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t^ 

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t^ 

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to  CO  ^ 

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t^ 

00  r^  01 

CO  On 

NO   to  1-1   1-1  NO 

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to  On  M 

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Mass. 
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Ohio 

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t^  lO  0  cooo 

pT  c?  c>  ^  Tt 

to    lO  P<  O 

PO  l-l  CO  to  PI 
W  PO  O  M  o 
NO  to  W  M  CO 
tC  H   CO  to  hT 
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SO  O  PO  PO  CO 
On  J>-  M  CO  M 
1  ■^00,  "t^^ 
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PI  Tt-SO 
M  CO  to 
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0) 

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CO 

Erie 

Escanaba    .... 
Evansville    .... 

Everett 

Fall  River  .... 

Findlay 

Fitchburg    .... 

Flint 

Fort  Wayne    .    .    . 
Framingham  (town) 

Frederick    .... 

Fresno      

Gardner  (town).    . 

Geneva 

Glens  Falls    .    .    . 

Gloucester  .... 
Gloversville     .    .    . 
Grand  Rapids    .    . 

APPENDIX  XVI. 


377 


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;  1  "I  I  "i 


ci   c3   cj   «S   o 


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378 


TYPHOID    FEVER. 


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cocoom  nOhcoOtI- 

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o'lncTco  ONrC-^Oco 

M     CO  P<  ^  H     M     I-" 


NO  On  in  On  m 

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OJ    ttJ  .rt    O  aj 


^5  h),"^ 

oi    nj    cti    cti    (D 


7^  9  c  « 


APPENDIX  XVI.  379 


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38o 


TYPHOID  FEVER. 


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p)   M  Tj-  in  -^ 

NO  NO  Tf  PO  0 

M               PI   NO      0 

00    ON  Tj- 

pi  M  m 

o 

rj-  t^vO    0   vo 

M  00    H  NO  in 

0     .   PO  Tj-  in 

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NO    H    M    M 

inNO     w     M    On 

t^    •    '^l-NO  00 

M                        H   00 

On  in  On 
H    w  NO 

o 

H 

On  -"l-OO  NO    M 

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in  inNO   0   PO 

Tj-    H      P<   00      W 

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PO                 On  'i- 

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H 
O 

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t~~  PI  00  00    PC 

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in    ■   fONO  in 

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d 

t^NO  NO 

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:  NO  4  tj-  ■ 

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•         -NO 

00 

a 

00 

16.  I 
42.4 

59-9 

P» 
•         •     PI 

a 

3 

1905  u.  s. 

Census 
Estimate. 

»0  M     0  NO    10 

00  00     0>  C<     0 
00    NO      W   NO      W 
NCT   10  O^0<^    pT 

rj-oo    Tj-  Ti-  0 
00    .^  t^NO    t^ 
00     On  On  M    m 

h"  pT  h"  pTncT 

H      H   NO      Tl-    H 
CO  P) 

NO     ^    0      M     t^ 
Tj-    Tl-    PO   0  00 
M  nO__    On  PO   0_ 

pT  in  .^no"  in 

M      H      PI      PI      M 

t^  PO  r>- 

M    On  PI 
On  M    PI 

o'no"  -4 

PI    PI  00 

i  i 

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M      0 

0    M    10  On  NO 

10  «   H  00   r^ 

00     10  M     10  m 

^    T?    C>   O^    M 

po  moo    On  P) 

00      H      M   NO    NO 

in  PO  t^  ^   On 
cT  in  pT  00"  ro 

M   00      0      PO    W 
P)      PI 

t^  OnOO     pi     PO 
NO     t^  PI     .*   t^ 
PI    H    PI    On  0 

H     PO   M     0"    -* 
M     H     PI     PI     H 

20,818 
23,898 
80,865 

4) 

Ind. 
N.  Y. 

Ohio 
Conn. 

Mass. 

N.J. 

Wis. 
Minn. 
Ala. 
N.J. 

N.J. 
Pa. 
N.  Y. 
Ind. 
Iowa 

Mich. 
N.  H. 
Tenn. 

b 

Michigan  City 
Middletown    . 
Middletown    . 
Middletown    . 
Milford  (town) 

MiUville  .    . 
Milwaukee  . 
Minneapolis 
Mobile     .    . 
Montclair    . 

Momstown 
Mt.  Carmel 
Mt.  Vernon 
Muncie    .    . 
Muscatine  . 

Muskegon  . 
Nashua    .    . 
Nashville     . 

APPENDIX  XVI. 


381 


-    PO  O      •  •    P*^     •    C^     •  10  VOO    i^Tj'i-PC  t^C"'"^  PlO^'      -t^ 

.POl-*-  .UO-P*.  )-(MMMMI-l  WCS'IO  POLO.-^ 

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•  t>.  t^oc  00  t1-piOp)0.  Orfiipir^vc  tJ-tj-^i-i  Opc-*Om 

O           HI  PC^PCPC--*  wwNwww  WLO-^O  iriPOPl'-tCO 

■^  PC  .^.X    O  i/",  Tj-  p)   r^o  OC    O    ■*  -^^C    Cs  <3    >-i   n  xn  r^t^po  pccC 

O  O    -^  O    P!  U-.  t^  LoO    iJO  vOpjpjpcOO  PCQPiO  ■*  PCO  00    O 

MWHiPiPi  re  PI          PC"  MHHP^MMP^  f-iwrj-pi  \Opc-h          pc 

vnoPCPC-*  -CCOC"  "CC-^omoc  ov  C^oo  r>-  r-»  r^  r^  Tj-  o, 

OOr^OCN  -tOOOp)  t^-^Ov  'LnO   o  «  vooo    pc  pi    O  O  00  ^ 

IM.-ICOIO'-I  PC-^'^Pl  l-ll-(MtHMl-l  CSWPCHi  pspc*-t              w 

OPCMt^-PC  .HwMpqu-)  PCt^PCiOi-i"*  vOiOMM  u-,OC  00    t^  ■* 

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■^PlPiPCi-'  i-HPCPC'^Pl  P)>hPji-iP<m  ►I'^-^Tt  C~-^P<           PC 

IC  P)    O    0-0  ii-TPiwoO  OpC"*CC^"*  OCOt^-'PC  "OPJI^On 

O00"*OO  CvTj-wQt^  0Op)O  t~~0  PCO    MM  t^  r^  o  r^  PC 

MWPCPOC*  WCVMtOPC  P1HMI-.WP)  PiPirC"*  ic           PCM'* 

.    "      .  .    Cn    .   I^    .  OC  00   r^  vcoo    On  PC    .      .      .  .      .      .  W)      . 

■  ■      ■    vo     ■  ■    iv^     "    On     ■  O    -+  i/~yOO    O    0\  O      "      ■      ■  ■      •      •  vo      ■ 

■  *         '      PC       "  ■      PI          ■      PC       ■  P)      M      P)      M      PI      h-l  P)          "          ■          ■  ■         "         ■      M          ■ 

_\0_  .On.O.  PCt^MPlOO  00...  ...CN. 

'      ■      '    \J->    '  ■    u-i     ■    **     ■  O  00  00    u-.oC    O  O      ■      ■      ■  •      ■      ■    n      ■ 

■p)'  'Pf'ly-l'  M             MMMPC  Pi"''  '''m' 

PC  .'"'.".  *^  u-><i    TJ~.  t>-  O  ^^     .      .      .  .      .      .    CN     . 

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■    PI      '  '    p^     ■  O      '  PI    M    PI    M    M    PI  M      ■      ■      •  *      '      '    w      * 


C^  w  00    P)    PI 
0   0   PI  0   0 
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PC  r^  PC  0  1^ 

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PC  Pi  0  X  X  0 

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r?          M    pp 

0^  Pi  X    iJ-> 
X    0    w    t^ 

Pi      M      PCO 

PC  o^o  ^ 

X     Pi     P<     W 

Pi 

0\   M      O-    t^    Pi 
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to  (>  icO"o" 
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0 
0 
0 

w" 

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X     -*   PI    ^    ON 
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20,006 
108,027 

17.54''^ 

287,104 

14,720 

Pi    t^  Pi    r^.  c>   M 
0    OX     0   C-   Pi 
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p< 
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Mass. 

Conn. 

Ind. 

Mass. 

Conn. 

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382 


TYPHOID  FEVER. 


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O    O    O    O    O  a   bcJi   a    u        titip^aj         rtcSS 

iz; iz; :z;  iz;  :z;  OOOOO     OOOpl,pm     PhPuPl, 


APPENDIX   XVI. 


383 


N  0  00 

ro    10 

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CO   •  t^  10  LO 

t^  0  00  10  0 

-it  C)  NO  C<  H 

PI 

On  On  t^  iJ^  0 

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a 

1 

igos  U.S. 

Census 
Estimate. 

M    OnnO    O    m 
M    li-)  rooo    O 

On  fT  OvNd~  On 
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M     VO    HI 

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CO  O     0 
to  CO  t^ 

CO  CO  t>^ 
VO  lO  HI 

s 

Pa. 
Mass. 
Ind. 
Va. 
N.  H. 

N.  Y. 
Me. 
N.  Y. 
Vt. 
Cal. 

Mich. 

Mo. 

Mo. 

Minn. 

Mass. 

Utah 
Tex. 
Cal. 

i 

b 

.    .    . 

Salt  Lake  City 
San  Antonio   . 
San  Diego  .    . 

Reading  .    . 
Revere  (town^ 
Richmond  . 
Richmond  . 
Rochester    . 

Rochester    . 
Rockland    . 
Rome  .    .    . 
Rutland  .    . 
Sacramento 

Saginaw  .    . 
St.  Joseph  . 
St.  Louis     . 
St.  Paul  .    . 
Salem  .    .    . 

APPENDIX   XVI. 


385 


CM» 

lf> 

0 

!>. 

Cv 

ir-. 

N 

0 

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t^ 

r^ 

0 

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0 

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APPENDIX  XVI. 


387 


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388 


TYPHOID  'FEVER. 


TABLE     II.  — BOSTON,    MASS.,   TABLE    OF   STATISTICS 
OF  TYPHOID    FEVER   FROM    1810-1906. 


(Illustrating  Chronological  Distribution.) 


Population. 

Typhoid  Fever. 

Typhus 

Fever. 

Year. 

Rate  per 

Rate  per 

Deaths. 

100,000. 

Deaths. 

100,000. 

1810 

33.787 

1811 

34,738 

'63 

181 

5 

1812 

35,689 

23 

64 

4 

1813 

36,640 

42 

124 

5 

1814 

37,591 

80 

202 

8 

1815 

38,542 

r 

51 

132 

5 

1816 

39.493 

23 

58 

3 

1817 

40,444 

59 

146 

2 

1818 

41,395 

119 

287 

0 

'1819 

42,346 

112 

265 

0 

1820 

43,298 

51 

117 

8 

1821 

45,107 

45 

99 

8 

1822 

46,916 

34 

72 

4 

1823 

48,725 

43 

88 

3 

1824 

50,534 

62 

122 

8 

1825 

52,343 

54 

103 

2 

1826 

54,152 

50 

92 

4 

1827 

55,961 

46 

80 

8 

1828 

57,770  . 

46 

79 

9 

1829 

59,579 

45 

75 

6 

1830 

61,392 

iZ 

53 

7 

1831 

63,684 

43 

67 

9 

1832 

65,976 

60 

91 

I 

1833 

68,268 

73  ■ 

106 

8 

1834 

70,560 

70 

98 

4 

1835 

72,852 

lOI 

138 

6 

1836 

75,144 

68 

90 

5 

1837 

77,436 

93 

120 

3 

1838 

79,728 

42 

42 

7 

1839 

82,020 

60 

73 

2 

1840 

84,311 

69 

81 

8 

1841 

89,614 

45 

50 

2 

1842 

95,251 

65 

68 

2 

1843 

101,242 

72 

71 

I 

1844 

107,610 

73 

67.8 

APPENDIX  XVI. 


389 


TABLE  II.  — TABLE  OF  STATISTICS  OF  TYPHOID 

FEVER. —  Continued. 


Typhoid  Fever. 

Typhus 

Fever. 

Years. 

Population. 

D« 

^,        Rate  per 
;aths. 

Deaths. 

Rate  per 

100,000. 

100,000. 

184s 

114,366 

97 

84.8 

1846 

118,551 

133 

112 

2 

1847 

122,890 

166 

541 

9 

1848 

127,387 

258 

202 

5 

1849 

132,048 

119 

90 

I 

1850 

136,881 

61 

44 

6 

1851 

141,308 

88 

62 

2 

1852, 

145,878 

46 

31 

5 

1853 

150,595 

44 

29 

2 

1854 

155,464 

38 

24 

4 

1855 

160,494 

12 

7 

5 

1856 

163,820 

70         42.7 

6 

3 

7 

1857 

167,218 

S3        49 

.6 

3 

I 

8 

1858 

170,685 

73        42 

■9 

2 

I 

I 

1859 

174,227 

74        42 

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i860 

177,840       I 

10        61 

.8 

1861 

180,646 

96        53 

.1 

1862 

183,497 

85        46 

•3 

1863 

186,390       I 

30        69 

•7 

1864 

189,331        I 

07        56 

■5 

10 

5 

3 

1865 

192,318       I 

25        65 

.0 

12 

6 

2 

1866 

194,506 

93        47 

.8 

8 

4 

I 

1867 

227,523 

86        il 

.8 

3 

I 

3 

1868 

231,024       I 

20        51 

•9 

I 

0 

4 

1869 

246,541        I 

38        56 

.0 

1870 

250,526       I 

68        67 

.  I 

1871 

258,032        I 

76        68 

.2 

1872 

265,764       2 

29        86 

.2 

1873 

321,200       2 

43        75 

.6 

1874 

331,395       2 

02        61 

.0 

1875 

341,919      7 

27        66 

■4 

1876 

346,004      I 

45        41 

■9 

1877 

350,138      I 

56        44 

.6 

2 

0 

6 

1878 

354,322      I 

20        zz 

•9 

1879 

358,554      I 

19        3i 

.2 

I 

0 

3 

1880 

362,839      I 

54        42 

■4 

1881 

368,190      2 

07        56 

.2 

1882 

373,620      2 

12        56.7 

390 


TYPHOID  FEVER. 


TABLE     II.  —  TABLE    OF  STATISTICS   OF   TYPHOID 
FEVER.  —  Continued. 


Population. 

Typhoid  Fever. 

Typhus  Fever. 

Years. 

Rate  per 

Rate  per 

Deaths. 

100,000. 

Deaths. 

100,000. 

1883 

379.129 

198 

52.2 

■ 
2 

0-5 

1884 

384,720 

216 

56 

I 

I 

0 

3 

1885 

390.393 

152 

38 

9 

1886 

401,374 

135 

iZ 

6 

1887 

412,663 

183 

44 

3 

1888 

424,274 

170 

40 

I 

I 

0 

2 

1889 

436,208 

186 

42 

6 

1890 

448,477 

155 

34 

6 

1891 

457.772 

154 

33 

6 

1892 

467,260 

137 

29 

3 

1893 

476,945 

148 

31 

0 

1894 

486,830 

141 

29 

0 

•1895 

501,083 

163 

32 

5 

1896 

516,305 

162 

31 

4 

1897 

528,912 

173 

32 

7 

1898 

541,827 

185 

34 

0 

1899 

555.057 

165 

29 

7 

1900 

560,892 

143 

25 

5 

1901 

567,617 

142 

25 

0 

1902 

574,465 

139 

24 

2 

1903 

581,357 

119 

20 

5 

1004 

588,320 

135 

22 

9 

1905 

595.380 

117 

19 

6 

1906 

602,440 

122 

20 

3 

The  data  for  the  years  before  1845  are  taken  from  the  Census  of 
Boston  for  1845  by  Lemuel  Shattuck,  Boston,  1846,  and  are  "  an  abstract 
from  the  Printed  Bills  of  Mortality." 

Subsequent  data  are  taken  from  the  last  annual  report  of  the  Boston 
Board  of  Health. 

In  the  early  records  "typhus  fever"  and  "typhoid  fever"  Mrere  con- 
founded. The  records  also  contain  references  to  "fever,"  to  "intermit- 
tent fever,"  "  remittent  fever,"  etc.,  many  of  which  were  doubtless  typhoid 
fever,  and  which,  if  included,  would  make  the  figures  from  25  to  50% 
more  than  those  given  in  the  table  under  "  typhus  fever." 


APPENDIX  XVI. 


391 


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392 


TYPHOID  FEVER. 


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<NCN)Cll-llHI-lMOJIHHHO)CM(NMHHHHMMHMHI-tl-ll-l 

■o  "3 

H 

1      'UOTJEI 

-ndo<j}0 

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O    CM    ^M    (NnOnO    rot^  -*NO  00    H  lO  lO  On'O    moO    INOO    O    H-^rOM    h 

■*  lO  IN    (N  NO    ^00    OnOOO    h    corfcot^t^iN    OnO    J^OnOn-*h    On  no  CO 
ro  O  00  NO   lO  r^NO   iri't'^ONt^oq   lOfOrOiOcq    '^M    w    m    -^pom    h    m 

M                                                                               WW 

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5 
a 
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r^NO  NO  NO    lO  OnOO  00    1-^  lO  O    OnOO    i^-OnW    LororO-^roO    OCO    t^CNi    t^ 
wio^rorO-^-^fOro-^O    On"*nO    '^lot^'^NO    -*ro  "000    lo  ro  W5  ro 

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w    r^rO'^PO<^iorO  ^nO  no    vonO    ^  pOnO  nO    '^lO'^POiOt^iOfOol    PO 

•jgqopo 

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CO  0<  NO'  'j-  <~0  rONO    ^  'i-NO    t^  r^  OnOO  nO    OnOO  nOnO    ^pDO    t^-^rO'^PO 

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W     01     (N     Ol     CNI     4>*POCOPO(NC>D     O     w     LOPOPOLOn     LO-^Ol     lO-^CN     W     01     01 
01     01 

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woiwwojoOPOwwwQnO    lo>0    oOw-^oirOWW           0104WNCJ 

w    w 

00    OnNO    oo  OnOO    I^oO^CnNO    0100    0  NO    w    Q    w    CO  t^  LO  On  "*  ■*  nO    ^nO    On 
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w    0    lonO  OO    w    lo  lo  On  Ol    LONO  NOOO    O    O    roCN-^oOrOONO    poloOn'* 
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00    roini^oor^Low    OnlooOwno    h  j^no   loh    woo   t^LoO    On^'^oO 
woiwwwro'd-        wOi^t^'^^McsNO'^-vi-woiwoq^rooioi 

•AjBiijqaj 

O    LO  On  oonO    ^ro-+0    wnO    wr^QNO    w    On  NO    oq    -^-^nO    ^-lopOiOOn 
wwoowoiwoioioioi    OONO  00    oooi    0100    ^oooi    w    w    wLorOw    w 

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t^  ro  01    01    0)    oo  On  NO    wQoor^wwNOG   t^oO    On  ^  oonO    w   r^  Q    On  r^ 
wNOoiTfoowdOioo  LONO    w   Tl-  \t-  r<700    oooi^oioioiONrDoioi 

•s 

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O     w     01     CO  'sf  LONO    t^OO     On  O     w    01     OO  '^  LONO    t^OO     On  O     w     01     OO  ■^  LONO 
OOOOOOOOOOOOOOOOOOOO     OnOnOnOnOnOnOnOnOnOnO     O     G     O     O     O     O 
OOOOOCOOOOOOOOCOOOOOOOOOOOOOCOOOOOCOOOOO    OnCnOnOnOnOnOn 

APPENDIX  XVI. 


393 


TABLE    IV.  — TYPHOID    FEVER    DEATH-RATES    IN 
CERTAIN   CANADIAN   CITIES   PER  100,000. 

(Compiled  for  the  Author  by  R.  S.  Lea,  Consulting  Engineer,  Montreal.) 


1  0 

a 

13 

bi 

i 

1 

6 

•g 

3 
0 

St.  Loui 
Sherbroo 

i 

0 

a 
0 

0 
1 

0 
0 
•a 
a 
0 
1-^ 

1 
1 
12 

a 

t-l 

m 

a 

1880 

44-3 

48.5 

35-6 

1881 

10.9 

66.1 

64.0 

20.  2 

42.6 

1882 

73-0 

70.6 

47.2 

112. 0 

49-7 

1883 

84.0 

80.9 

30.5 

52.3 

33-1 

1884 

51-8 

63.0 

38.2 

62. 1 

39-2 

33 

8 

1885 

12.2 

58.6 

20.0 

26.6 

26.5 

41 

2 

1886 

34-5 

45-7 

26.4 

53-7 

12.6 

47 

8 

1887 

105.0 

61. 1 

46.2 

22.3 

37-0 

63 

9 

1888 

37-5 

51.8 

30-9 

29.8 

24.7 

76 

5 

1889 

41. 1 

40.5 

36.0 

II-3 

63-5 

97 

0 

1890 

40-3 

93-5 

28.6 

26. 1 

60.2 

63 

0 

1891 

30-9 

93-9 

24-5 

38.8 

67.3 

94 

2 

1892 

24.6 

42.0 

28.2 

43-3 

71.9 

7 

8 

1893 

37-6 

39-5 

10. 0 

27-5 

25-4 

38 

5 

1894 

39-S 

23-4 

17.8 

21.2 

20.2 

68 

4 

'8.6 

1895 

47.8 

28.9 

23-5 

37-1 

79-4 

120 

0 

0 

1896 

21-5 

20.5 

...   62 . 

9  34-5 

24-5 

27.2 

21.5 

59-0 

7-9 

1897 

31-9 

22.  I 

...   71. 

I  51.2 

18.2 

9.6 

24-3 

24.5 

66 

5 

12.9 

1898 

25-3 

II  .0 

•■•  43- 

8  42.3 

16.0 

13-3 

36.0 

53-1 

65 

9 

48.3 

1899 

20.  6 

14-3 

...   17. 

0  52.1 

20.3 

31-9 

14.9 

14.4 

137 

0 

29.8 

1900 

46.7 

7-3 

0   16. 

8  38.4 

20.1 

30-4 

26.3 

22.3 

78 

0 

164.5 

1901 

50.2 

I3-I 

18.2  34. 

0  21.7 

17.8 

19.0 

15.8 

39-0 

36 

I 

125.2 

1902 

34-0 

10. 1 

17.4  16. 

7  31-3 

14-3 

18.8 

0 

5-5 

35 

8 

95-2 

1903 

42.6 

12.7 

7.1  49- 

4   9-5 

18.2 

7.6 

7.8 

99-5 

36 

0 

109.3 

1904 

50-5 

9.8 

50-7  31- 

3  19-8 

25.8 

16.8 

42.5 

22. 1 

5° 

0 

248.5 

1905 

22.4 

II  .2 

JO. 6  31. 

9  20.7 

18.7 

23-9 

24.6 

38.5 

10 

8 

222.8 

1906 

48.7 

8.3 

56.4  33- 

S  33-6 

31-4 

34-8 

36.2 

38.4 

52 

8 

152.2 

1907 

50.0 

Population  Estimates  for  igo6. 


Montreal 312,923 

Toronto     .    .    .    .  - .  222,903 

Winnipeg 101,000 

Ottawa 74>342 

Quebec      72,034 

Hamilton $4,562 


London      ......  41,397 

St.  Louis 19,660 

Brantford 18,973 

Kingston 18,218 

Sherbrooke 12,759 


394 


TYPHOID  FEVER. 


Pi 
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Q 

< 

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o 
p 

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to 

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Q 
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5  K 

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n  n 

46    «    cod    6    corj    Oivooooo    loinioioo    rrod    Tf 

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(3* 

t^t^i/ivO    loo    r--cor^ 

loo   loTto    o-^co\o   r^vo 

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O    CO 

c 

r^t^oc    ino^ooooo    o    o    r^oo    m    o    f^oo   t^oo    c>o    for^ 

loo 

O  00 

0) 

M      M 

MM                 M                            MM 

MM                                                             M 

> 

0 

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0\(N    CNOvO    HVO    -^O 

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COCOCOCO^O     C-)     «     OvCO^O     O' 

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°        ". 

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looovOr^vOM    CI    MO    oo    M 

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« 

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o    ^ 

tC   rC 

3 

«        ■* 

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I^O     coo     OCS     lOOvCM     >00 

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APPENDIX  XVI. 


395 


TABLE   VI.  — TYPHOID  FEVER  DEATH-RATES  IN 
CERTAIN  CITIES  OF  FRANCE. 

(After  Debauve-Imbeaux.) 


Name  of  City. 


Paris 

Lille 

Roubaix 

Rheims 

Nancy 

Lyon 

Saint-Etienne      .... 

Marseille 

Toulon 

Nice 

Toulouse 

Bordeaux     

Rouen      

Le  Havre 

Nantes 

Total  for  56  cities 
of  France    .    .    . 


Population  in 
1901. 


2,714,068 
210,069 

124,365 
108,385 
102,559 

459,099 
146,559 
491,161 
102,118 
105,109 

149,841 
256,638 
116,316 
130,196 
132,990 


7,521,151 


Typhoid  Fever  Death-rate  per 
100,000. 


1886-1889 


45-2 

195 
27.0 
44.2 
55-7 

29-5 

28.7 

104.2 

106. 2 

85-7 

80.2 
62.0 

72-5 

195-5 

51-7 


52-1 

For  the 

year  1886 


1890-1898  1899-1903 


20.  o 
13-7 
23-5 
30-4 
57-4 

23.8 
28.0 

67-3 
109.  2 

51-8 
35-8 


19-3 
09.8 
17.2 
28.6 
31.2 

21 . 1 

23-9 

40.7 

95-9 
30.7 

24.8 
17.4 
40.6 
87.0 
36.2 


21.2 

For  the 

year  1903. 


396 


TYPHOID   FEVER. 


TABLE  VII.  — TYPHOID    FEVER    DEATH-RATES  FOR  CER- 
TAIN GERMAN  CITIES    PER    100,000. 


>> 

rj 
1 

1 

i 

1 

a 
1 

(5 

0. 

;3 

a 

S 
0 
(J 

ti 
0 

a 

■S 

'S 

:o 
i4 

> 
0 

c 

1 

a 

a 

1885 

16.3 

34-0 

21.3 

17.2 

13.8 

15-9 

131 

13.0 

42.4 

9-3 

7-2 

6.8 

1886 

13 

3 

65-3 

16.9 

19.7 

17 

8 

8.2 

12.4 

12.3 

41.2 

16.6 

8-5 

9.2 

1887 

13 

6 

85-9 

15-6 

9-3 

10 

8 

9.0 

II. 9 

6.1 

41.9 

6.6 

6.8 

6.6 

1888 

12 

8 

52.2 

14.6 

9.8 

9 

8 

6.7 

9.4 

8.3 

80.9 

10.4 

8.2 

6.5 

1889 

19 

0 

41.0 

II. 2 

9.4 

7 

7 

"•3 

16.7 

8.6 

17-5 

II. 8 

6.5 

S-9 

1890 

9 

I 

26.2 

14.8 

8.0 

7 

6 

II. 8 

8.5 

7.8 

16. 1 

7-3 

2.1 

9-5 

I89I 

10 

4 

26.2 

II. 4 

6.6 

7 

9 

151 

131 

5-8 

22. 7 

5-2 

7.0 

13.2 

1892 

8 

3 

34-5 

14.8 

2.9 

5 

3 

8.0 

II. 4 

7-5 

13.8 

6.1 

4-7 

9.8 

1893 

9 

4 

17.6 

9.8 

14.8 

4 

8 

7.0 

18.3 

4.4 

13-7 

8.0 

8.6 

17.7 

1894 

4 

2 

6.0 

6.8 

2-5 

8 

0 

9-7 

6.7 

6.3 

16.4 

7.2 

S-8 

5-8 

189s 

5 

7 

9.2 

9.9 

3-6 

S 

I 

8.3 

8.4 

5-2 

8.1 

6.4 

4.4- 

6-3 

1896 

4 

7 

5-4 

7-1 

3-2 

4 

3 

7.6 

5-8 

4-5 

16.0 

6.8 

6.2 

7-5 

1897 

4 

0 

7-1 

10.9 

5-1 

3 

3 

9.0 

8.5 

5-1 

10. 1 

3-6 

1.2 

31 

1898 

4 

3 

4.6 

6.9 

3-3 

4 

3 

8.1 

II. 4 

1-5 

9.9 

S-8 

3-7 

4.4 

1899 

4 

I 

3-7 

22.8 

31 

7 

3 

7.6 

8.6 

3-7 

13.0 

7-7 

3-1 

1900 

5 

8 

3-4 

10.6 

4 

I 

4-3 

I90I 

4 

7 

6 

4 

1902 

2 

7 

4 

0 

3-5 

1903 

3 

2 

5 

3 

1904 

3 

7 

2 

8 

1905 

5 

3 

3 

7 

3-2 

3-7 

APPENDIX    XVI.     TYP 

TABLE   VIIT.    TABLE  SHOWING  THE  NUMBER  OF  DEATHS  FI 
WHICH   HAVE   A   POPULATION    OF    loo,ood 


Cities. 


Allegheny,  Pa. 
Baltimore,  Mo. 
Boston,  Mass. 
Buffalo,  N.  Y. 
Chicago,  111.    . 

Cleveland,  Ohio 
Columbus,  Ohio 
Denver,  Colo. 
Detroit,  Mich.    . 
Fall  River,  Mass. 


Indianapolis,  Ind. 
Jersey  City,  N.  J. 
Kansas  City,  Mo. 
Los  Angeles,  Cal. 
Louisville,  Ky.    .    . 

Memphis,  Tenn.  . 
Milwaukee,  Wis.  . 
Minneapolis,  Minn 
Newark,  N.  J.  .  . 
New  Haven,  Conn 

New  Orleans,  La. 
New  York,  N.  Y. 

Manhattan 

Bronx  .    . 

Brooklyn . 

Queens    . 

Richmond 

Omaha,  Neb.. 
Paterson,  N.  J.  . 
Philadelphia,  Pa. 
Pittsburg,  Pa. 
Providence,  R.  I. 

Rochester,  N.  Y. 
San  Francisco,  Cal 
Scranton,  Pa. 
St.  Joseph,  Mo. . 
St.  Louis,  Mo.    . 

St.  Paul,  Minn. 
Syracuse,  N. Y. 
Toledo,  Ohio 
Washington,  D.  C. 
Worcester,  Mass.  . 

Cincinnati,  Ohio    . 


Population. 


78,582 

362,839 
155.134 
503.185 

160,146 
51.647 
35.629 

116,340 
48,961 

75.056 
120,722 

55.185 

11,183 

123,151 

33.592 

115.587 

46,887 

136,508 

62,i 

216,090 

1,897,712 
1,164,673 

41,626 

599,495 
52.927 
38,991 

30,518 

51,031 
847,170 

156,389 
104,857 

89,366 

233,959 

45,850 

32,431 

350,518 

41,473 
51,792 

50,137 

177,624 

58,291 

296,908 


105,287 
434,439 
448,477 
255,665 
,099,850 

261,353 

88,150 

106,713 

205,876 

74,398 

105,436 
163,000 
132,716 

50,395 
161,129 

64,495 
204,468 
164,738 
181,830 

81,298 

242,439 
2,487,840 
1,441,216 

74.085 

838,547 
82,299 
51.693 

140,452 

78.347 

1,046,964 

238,617 

132,146 

133,896 

298,997 

72,215 

52,324 

451,770 

133,156 
88,143 
81,434 

230,392 
84,655 

255,139 


129,896 

508,957 
560,892 

352,387 
,698,575 

381,768 
125,560 

133.859 
285,704 
104,863 

169,164 
206,433 
163,752 
102,419 
204,731 

102,320 

285,315 
202,718 
246,070 
108,027 

287,104 
3,437,202 
1,850,093 

200,507 
1,850,093 

152,999 
67,021 

102,555 
105,171 

1,293.697 
321,616 

175,597 

162,608 
342,782 
102,026 
102,979 
575,238 

163,065 

108,374 
131,822 
278,718 
118,421  128,135 


142,848^ 
546,217 
595-380 
372,088 

1,932,315 

425,632 
142,105 
150,317* 

325,563* 
105,762 

212,198 

232,699 

179,272* 

200,000 

222,660* 

121,235* 

312,948* 

261,974* 

283,289 

119,027* 

309,639* 
4,000,403* 
2,102,928 

271,592 
1,355,106 

197,838 
72,939 

120,565* 
111,529 
1,850,093 
364,161 
198,635* 

182,022 

364.677 

116,111* 

"5.479* 

636,973* 

191,023 
117,129* 

155,887 
302,883* 


1880  1881 


44 
196 

154 

171 

70 


35 


43 


98 
197 
207 
no 
568 

169 


32 


79 
135 


59 


116 

165 
212 
121 
462 


51 


156 


119 


42 


61 
26 
98 

63 
361 

123 


33 


33 


51 


41 

151 
216 

82 
354 

121 


26 


116 


155 


47 


69 
155 
152 

47 
496 

71 


32 


152 

29 

44 


94 
17 

38 


372  594516625  476  405: 
The  figures  for  th 
71  99  93  92  107  153 


26  32 


498:645 
II  2 
53  38 

26 
90 


139 


325.902 


341,444  178 


191 


91 


153 


38 


650 
268 

140 

30 
152 


166 


579 
188 
128 

39 

163 

26 


16 


662 
130 

52 

49 

150 

25 


166 


60  77 


123 


21  28 


183 


146 


20  .  .  . 
118  153 


136 


152 


21 

610 

154 

44 

32 
118 

33 

125 

44 
14 
16 

134 
19 

116 


*  U.  S.  Census  Estimate. 


)ID 

FEVER 

STATISTICS. 

M  TYPHOID  FEVER  IN  THE  CITIES  OF  THE  UNITED  STATES 

)R  OVER  FOR  THE  YEARS  l88o  TO  1906. 

Deaths  from  Typhoid  Fever  by  Years. 

il887 

1888 

1889 

1880 

1891 

1892 

1893 

1894 

1895 

1896 

189^ 

189[ 

]\m 

19Ct 

1901 

1905 

i9o: 

1904 

190c 

1906 

■  no 

106 

106 

146 

96 

171 

161 

99 

227 

59 

7S 

73 

135 

121 

135 

I4S 

12^ 

i6e 

182 

187 

■156 

161 

191 

247 

150 

193 

22,^ 

222 

173 

1 88 

185 

185 

153 

i8g 

141 

22c 

185 

195 

197 

183 

183 

170 

186 

155 

154 

137 

148 

141 

163 

162 

173 

185 

165 

143 

142 

139 

iig 

135 

117 

122 

77 

68 

73 

105 

129 

98 

112 

185 

87 

68 

69 

9S 

87 

9c 

98 

125 

^33 

91 

9c 

90 

382 

375 

453 

1008 

1997 

1489 

670 

491 

518 

751 

437 

636 

442 

337 

509 

801 

588 

373 

329 

370 

120 

113 

185 

180 

137 

167 

^53 

89 

117 

143 

79 

121 

118 

205 

140 

^33 

472 

204 

67 

93 

36 

65 

48 

45 

46 

47 

56 

49 

29 

33 

31 

53 

47 

44 

46 

195 

109 

52 

lOI 

134 

188 

287 

99 

64 

71 

59 

43 

91 

63 

41 

49 

43 

48 

65 

60 

45 

52 

98 

116 

86 

62 

39 

73 

209 

97 

67 

56 

57 

38 

58 

35 

50 

58 

60 

53 

5° 

45 

70 

45 

46 

48 

209 

49 

27 

62 

33 

30 

25 

32 

21 

II 

15 

21 

14 

27 

19 

II 

9 

52 

no 

56 

140 

80 

64 

65 

74 

79 

63 

88 

108 

122 

412 

75 

81 

114 

132 

159 

^67 

123 

116 

96 

174 

158 

38 

79 
41 

39 

44 
60 

33 
71 
33 

44 
60 

36 
132 

53 

46 

70 
54 

45 
98 

54 

45 
52 
45 

35 

37 

19 

'28 

22 

'36 

43 

31 

"28 

25 

44 

41 

47 

44 

120 

133 

144 

142 

130 

116 

135 

145 

126 

131 

93 

126 

132 

106 

104 

108 

157 

112 

113 

137 

42 

45 

37 

35 

45 

21 

22 

41 

32 

32 

28 

23 

39 

36 

44 

34 

45 

55 

34 

34 

55 

78 

55 

83 

71 

66 

80 

60 

63 

46 

31 

46 

47 

59 

63 

48 

54 

43 

68 

95 

156 

114 

65 

100 

84 

146 

lOI 

86 

67 

157 

89 

77 

79 

132 

65 

lOI 

103 

55 

87 

'84 

76 

131 

194 

134 

153 

63 

43 

43 

61 

44 

31 

85 

25 

53 

50 

61 

38 

40 

53 

24 

38 

24 

24 

18 

26 

28 

28 

32 

28 

25 

36 

30 

28 

107 

43 

42 

31 

49 

63 

34 

46 

41 

50 

59 

SI 

39 

76 

113 

90 

141 

184 
676 
353 

155 
546 
278 

114 

718 
342 

141 

728 
380 

135 
764 

365 

119 
653 
317 

III 
661 

lOI 

649 
273 

95 
639 
325 

421 

364 

397 

352 

384 

400 

381 

326 

322 

297 

299 

277 

ronx  are  included  in  th 

ose  fo'-  Manhattan 

23 

16 

30 

32 

34 

33 

32 

37 

44 

143 

153 

161 

182 

180 

162 

179 

159 

173 

163 

173 

270 
16 

205 
27 
20 

301 
32 
13 

24 

272 

27 
16 

322 
32 

I  I 

267 
22 

303 
34 
15 

19 

297 

31 
II 

230 

30 
10 

14 
32 

14 
II 

97 

63 

46 

50 

28 

19 

22 

40 

29 

18 

22 

26 

23 

20 

32 

48 

16 

19 

18 

18 

15 

33 

28 

21 

47 

49 

35 

34 

49 

27 

36 

24 

7 

16 

6 

621 

785 

736 

666 

683 

440 

450 

370 

469 

402 

401 

639 

948 

449 

444 

588 

744 

957 

684 

1063 

269 

191 

218 

315 

249 

256 

292 

152 

213 

175 

184 

218 

342 

464 

416 

475 

474 

503 

380 

519 

39 

103 

59 

39 

62 

51 

50 

70 

46 

40 

24 

39 

42 

41 

47 

36 

37 

28 

35 

39 

38 

54 

39 

43 

50 

71 

58 

18 

43 

26 

35 

19 

32 

30 

31 

19 

21 

29 

19 

31 

64 

93 

160 

^33 

128 

99 

99 

118 

108 

85 

62 

136 

74 

46 

77 

98 

10 

100 

91 

9 

31 

20 

18 

28 

33 

24 

21 

33 

24 

15 

14 

25 

32 

24 

18 

13 

13 

22 

'64 

17 

22 

19 

28 

22 

14 

12 

14 

9 

9 

10 

10 

1^6 

^33 

140 

137 

172 

514 

171 

172 

100 

118 

119 

99 

149 

168 

198 

222 

287 

215 

124 

112 

145 

135 

lOI 

74 

65 

57 

59 

37 

41 

43 

25 

41 

32 

39 

24 

24 

18 

27 

20 

41 

20 

27 

22 

29 

40 

33 

34 

41 

31 

30 

24 

45 

26 

31 

20 

10 

6 

12 

18 

II 

23 

25 

28 

38 

23 

35 

25 

31 

40 

37 

37 

31 

40 

51 

40 

52 

40 

56 

71 

70 

167 

188 

213 

257 

186 

216 

202 

228 

235 

148 

130 

191 

199 

220 

172 

226 

140 

135 

140 

161 

13 

2 

25 

15 

18 

19 

31 

31 

25 

14 

15 

13 

19 

32 

26 

18 

17 

5 

27 

IS 

403 

203 

142 

205 

186 

121 

^34 

169 

120 

164 

lOI 

105 

121 

119 

182 

206 

150 

270 

155 

239 

TABL 

TABLE  SHOWING  THE  NUMBER  OF  DEATHS  FROM  TYPHOID 
POPULATIONS  BETWEEN  50,000  AND 


Cities. 


Albany,  N.  Y.     .    . 
Atlanta,  Ga.   .    .    . 
Bridgeport,  Conn. 
Cambridge,  Mass.. 
Camden,  N.  J.    .    . 

Charleston,  S.  C.  . 
Dayton,  Ohio  .  . 
Des  Moines,  Iowa 
Duluth,  Minn.  .  . 
Elizabeth,  N.  J. .    . 

Erie,  Pa 

Evansville,  Ind. 
Grand  Rapids,  Mich 
Harrisburg,  Pa. 
Hartford,  Conn.     . 

Hoboken,  N.  J. 
Kansas  City,  Kas. 
Lawrence,  Mass.    . 
Lowell,  Mass.     .    . 
Lynn,  Mass.   .    .    . 


Manchester,  N.  H. 
Nashville,  Tenn.    . 
New  Bedford,  Mass, 
Oakland,  Cal.     .    . 
Peoria,  111 


Portland,  Me.  . 
Pordand,  Ore.  . 
Reading,  Pa.  .  . 
Richmond,  Va.  . 
Salt  Lake  City,  Utah 

San  Antonio,  Tex. 
Savannah,  Ga.    . 
Seattle,  Wash.    .    , 
Somerville,  Mass.  . 
Springfield,  Mass. 


Trenton,  N.  J.  . 
Troy,  N.  Y.  .  . 
Utica,  N.  Y.  .  . 
Wilkesbarre,  Pa. 
Wilmington,  Del. 


Population. 


3o>75 

37.409 

27,649 

52,669 

41,659 

49,984 
38,678 
22,4 

28,229 

27>737 
29,280 
32,016 
30,762 
42,015 


3,200 
39>i5i 
59,475 
274 

32,630 

43,350 
26,845 

34,555 
29,259 

33,810 
17,577 
43,278 
63,600 
20,768 

20,550 
30,709 
3,533 
24,933 
33,340 


94,923 
65,533 
48,866 
70,028 
58,313 

54,955 
61,220 
50,093 
33,115 
37,764 

40,634 

50,756 
60,217 

39,385 
53,230 


30,999  43, M 
38,316 
44,654 
77,696 

55,727 


29,110 

56,747 
•33,914 

42,478 


44,126 
71,168 

40,753 
48,682 
41,024 

36,426 
46,385 
58,661 
81,388 
44,243 

37,673 

43 

42,»37 

40,152 

44,179 


57,458 
60,956 
44,007 
37,718 
61,431 


94,151 
89,872 
70,996 
91,886 
75,935 

55,807 

85,333 
62,139 

52,969 
52,130 

52,733 
59,007 

87,565 
50,167 
79,850 

59,364 
51,418 
62,559 
94,969 
513 

56,987 
80,865 
62,442 
66,960 
56,100 

50,145 
90,426 
78,961 
85,050 
53,531 

53,321 
54,244 
80,671 
61,643 
62,059 

73,307 
60,651 

56,383 
51,721 
76,508 


79,848* 
102,70 
82,061* 

96,324 
81,877 

56,147* 

98,350 

75,626* 

64,942* 

60,509 

58,783 
63,132 

97,756* 

54,807 

93,160* 

65,468 

67,614* 

70,050 

94,889 

77,042* 

63,417* 

84,227* 

74,362 

72,670* 

65,026* 

54,330* 
104,141* 
89,111 
86,880* 
58,914 

61,146* 

67,311 

99,586* 

69,272 

73,540 


76,271* 
63,647* 
58,721* 
83,860* 


1880 1881 1882 1883 1884 1885 18! 


13 


32 


17 


27 


26 


58 


38 


14 


39 


24 


72 


43 


49 


31 


13 


17    20 
43 


16 
120 


16    2; 


51 


45 


*  U.  S.  Census  Estimated. 


[X. 

:VER  IN  THE  CITIES  OF  THE  UNITED  STATES  WHICH  HAVE 
i,ooo  FOR  THE  YEARS   1 880  TO   1906. 


Deaths  from  Typhoid  Fever  by  Years. 


87 1888 


1891 1892 1893 


1894 1895 1896 1897 1898 1899|1900il901 


1902il903 1904 1905'1906 


74 

105 

8 

27 

55 


30  40 

15  18 


26 


15 


62  IC 

99 
3 

17 


56 


24 


41 


58 

63 
12 
16 

38 

24 
46 

22 
53 


24  33 

50  57 


28  32 


14  15  10 


17 


30 

lOI 

14 

21 
96 
33 
25 
36 


97 


30 
3 

44 

47 

14 

112 

8 

19 
27 

9 

9 

30 


94  82  38 

56  77  52 

10 

14 

23 

73 
18 

17 


77 

8 

20 

49 

61 
31 
13 

34  22 

7  5 


66  83 
18 

17 
16 


29  19 


36 


7  13 


42  48  44  35  33 


37 


14 


35 


24 


19  17 


14  19  12  16 


13 


17 


20 
66 
10 
II 


45 


29 


42 
28 

30 


39 


6  10 


17 
26 


34 

7 


32 


60 

125 


21 


28 

13 
14 
16  10 


7 
19 

20 
46 


30 


49 
88 

II 

25 
II 

55 


15 


35 


28 
58 
20 


14 
39 

15 

27 
20 

29 


44  29 


39 


27 


36 
12 
29 

26 
II 

16 

28 
9 

15 


14 


17 


36 
20 

45 
29 
23 


20  II 
18  17 
13  13 


15 


52 
18 

24 
15 
15 

33 
48 

9 
■46 


39 

22 

13 
23 

19 
33 

40 

75 
14 

23 
16 

24 

9 

17 

26 
76 


36 


38 

19 

6 

15 

15 
23 
35 
32 

20 

33 
17 
26 
12 
16 

14 

42 

9 

32 


17 
34 
55 
37 
31 

23 
26 

29 
6 

13 

29 
37 


41 


17 
17 

13 
46 
12 

15I  30 


15  14 
17  7 

16  14 


15 
34 
3c 
51 


36 

34 

33 
10 

17 

45 
25 


15 
25 
29 
34 
27 

30 
51 
35 


6 

63 
8 

29 


9 
35 
34 
41 


35  36 


54 


36 
34 


43 


37 
II 
16 


34 

28 


19 
34 


INDEX. 

PAGE 

Aeration  in  streams • 55 

Age ■ 103 

Agglutination 11,  320 

Albany,  N.  Y 77,  123,  238,  263,  276,  280,  369 

Alcoholic  beverages 91 

Algae  growths 58 

Allegheny,  Pa 158 

Allied  diseases 6,  222,  278 

Animals  not  susceptible  to  typhoid  fever 10,    11 

Army  camps 68 

Artificial  ice 62 

Atlantic  coast 114 

Augusta,  Me 154,  260,  369 

Auxerre,  France 185,  369 

Bacillemia  in  typhoid  fever 325 

Bacillus  typhosus  (B.  typhi)      1-8,  314,  322,  332,  337,  344 

Bacteriology  of  typhoid  fever 8 

Baltimore,  Md 122,  124,  259 

Bangor,  Me 178,  260 

Baraboo,  Wis 179,  369 

Barriers  against  spread  of  typhoid  fever 22,  23,  28,  34 

Barnes'  Well,  Ithaca 226 

Basingstoke,  England 183 

Beaches 120 

Berlin,  Germany      394 

Binghamton,  N.  Y 77,  242,  280 

Blood,  in  typhoid  fever 13 

Blood  tests 17.  35 

Bloomfield,  N.  J 204 

Board  of  Health 26,  70,  84 

Boats,  pollution  from 238 

397 


398  INDEX. 

PAGE 

Boiling  water 86,  289 

Boston,  Mass 122,  124,  252,  388 

Bowers,  George 176 

Breath 19 

Brooklyn,  N.  Y 256 

Bulstrode,  Dr 206 

Burlington,  Vt 171,  369 

Butler,  Pa.     .    .    .    : 193,  369 

Buxton,  Dr.  B.  H 13,  322 

Canadian  cities 393 

Carbolic  acid 29,  289,  292 

Carriers  of  typhoid  fever 19,  213 

Caterham,  England 369 

Cause  of  typhoid  fever    .....' 10,  21,  131 

Celery 209 

Census  data 100,  303 

Certified  milk 79 

Cesspools       32,  65,  290 

Cesspools,  fate  of  typhoid  bacillus 52 

Charleston,  S.  C 122 

Chemical  disinfection 289 

Chicago  Drainage  Canal 51,  162,  246 

Chicago,  III 122,  161,  164,  369,391 

Children 6,  33,  106,  108 

Chloride  of  lime       29,  289,  291 

Cholera 7 

Chronological  distribution 128 

Classification  of  epidemics 135 

Cleanliness 32,  78,  85 

Clean  water  and  how  to  get  it 248 

Cleveland,  Ohio 166,  235,  369 

Climate      114 

Cockles 209 

Coleman,  Dr.  Warren 13,  322 

Collection  of  typhoid  data      217 

Colored  race m 

Columbus,  Ohio 369 

Complications  in  typhoid  fever S>  97 

Conduits,  purification  of  water  in 60 


INDEX.  399 


PAGE 


Conn,  Dr.  H.  W 20^ 

Contagion      ' 23,  148 

Contaminated  waters 230,  282 

Control  of  epidemics ' 223 


Convalescence 


5>  33 


Copper  sulphate 224,  294 

Cornell  University ■ j^2 

Corrected  death-rates 707 

Corrosive  sublimate 29,  280    293 

Cost  of  typhoid  fever 27<;    367 

Currents  in  lakes i??    iiO 

Data,  collection  of 218 

Data,  study  of 210 

Date  of  infection      220 

Dead  ends '       53 

Death-rates 03    94  91; 

Defense,  lines  of,  against  the  typhoid  bacillus 69,  70,  85,  89 

Defenses  of  the  body  against  typhoid  fever ir 

Delaware  River 246 

Depreciation  of  polluted  water      278 

Diagnosis  of  typhoid  fever 2,  317 

Diazo  reaction ,20 

Diet jjo 

Dilution r^ 

Disinfectants 29    287 

Disinfection 25,  28,  35,  287 

Disinfection  of  water  supplies 224 

Dispersion  in  lakes cy 

Distribution  of  typhoid  fever jo? 

Drigalski-Conradi  Agar ,7, 

Duration  of  typhoid  fever e 

Dust 42 

Dysentery » 


II 


Eberth  bacillus , • 

Educational  work 84 

Emsworth,  England 206 

Endless  chain ' 21 

England 129 


400  INDEX. 

PAGE 

Entry  of  typhoid  bacilli  into  the  body 12 

Epidemics      134,  209,  214 

Errors  in  death-rates 96 

European  death-rates      116,  117 

Exit  of  typhoid  bacilli  from  the  body 17 

Fabrics,  typhoid  fever  in 68 

Far  Rockaway,  L.  1 206 

Fatality  of  typhoid  fever 96,  99,  105 

Fecal  matter,  disposed  of 31,  38 

Feces,  typhoid  bacilli  in 49 

Filters,  house 86 

Filtration  of  water 73>  77;  247,  276 

Financial  aspect  of  typhoid  fever        273 

Fire  connections 177,  178 

Flies 39,  67,  88,  198,  296 

Flies,  epidemic  due  to 135,  191,  196 

Focus  of  infection 21 

Food  of  typhoid  bacillus 45 

Food  supplies,  supervision  of 83 

Formaldehyde 294 

France,  cities  of 395 

Frankfort-on-the-Main 231 

Freezing 45 

Fruit,  epidemic  due  to 136,  207,  209 

Fuertes,  James  H 228 

Fulton,  John  S 96,  113 

Fumigation 294 

Gastric  juice 12 

Gelsenkirchen 148 

Geological  distribution 119 

Geographical ^ 115 

German  cities 71,  396 

Glasgow,  Scotland 268 

Gorgas,  Col.  W.  C i97 

Ground  waters 74,  185,  186,  188 

Hamburg,  Germany 235 

Hansen,  Paul 248 


INDEX.  401 

PAGE 

Hazen,  Allen 248,  277 

Health  tone , 89 

Heat,  as  a  germ  destroyer 288 

Horton,  Theodore 251 

Howard,  Dr.  L.  0 296 

Hudson  River 238,  260,  263,  369 

Hydrographic  distribution 120 

Hypersensitiveness 14 

Ice,  epidemic  due  to 136,  208 

Ice,  handling  of 63 

Ice,  longevity  of  typhoid  bacillus      61,  62 

Immunity  to  second  attack 109 

Incubation  period 2,  220 

Infection,  vehicles  of 22 

Inspected  milk 79 

Intestinal  disinfectants 24 

Intestinal  disorders 14 

Investigation  of  epidemics 216 

Iron  sulphate 294 

Isolation '- ^^ 

Ithaca 142,  214,  226,  369 

Jackson,  D.  D 121-300 

Japanese-Russian  War 197,  362 

Japanese  water  supplies 117 

Jersey  City,  N.  J 233 

Jordan,  Dr.  E.  0 193 

Kennebec  River 154,  263 

Lake  steamer,  outbreak  on 179 

Lausen,  Switzerland 181,  369 

Lawrence,  L.  1 206,  369 

Lawrence,  Mass 77,  149,  152,  236,  261,  279,  370 

Leighton,  M.  0 273 

Lemon  juice,  effect  on  typhoid  bacillus 91 

Levy,  Dr.  E.  C 154,  337,  371 

Life-savers 214 

Lime 30,  289,  290 


402  INDEX. 

PAGE 

Limestone  regions  and  typhoid  fever 120,  183 

Lincoln,  England 106 

Literature  of  typhoid  fever 368 

Liverpool,  England 270 

London,  England 124,  269,  394 

Longevity  of  the  typhoid  bacillus.    .    .       46,  50,  63,  65,  66,  67,  68,  344 

Lorain,  Ohio 261 

Lowell,  Mass 149,  152,  174,  235,  370 

Lynch,  Major  Charles 197 

Malaria      96 

Manila,  Philippine  Islands 118,  119 

Marine  Hospital  Service 272 

Marlborough,  Mass 202,  370 

Medicine  in  peace  and  war 362 

Merrimac  River 150,  176,  263 

Messalonskee  stream 157 

Microscopic  organisms,  effect  on  typhoid  bacillus 58 

Middletown,  Conn 204,  370 

Military  camps .     195,  356 

Milk,  dangers  from  diet 78,  126,  268 

Milk,  epidemic  due  to 136,  198,  199,  201,  202,  204 

Milk,  longevity  of  typhoid  bacillus 65 

Milk  supplies  and  death-rates 267 

Millinockett,  Me 177 

Mississippi  River 243,  265 

Moisture 42 

Monongahela  River 159 

Montclair,  N.  J 204,  285,  370 

Morbidity  statistics      99 

Mount  Savage,  Md 188 

Multiplication  of  typhoid  bacilli  in  the  body 12 

Musca  domestica       296 

National  Department  of  Health 284 

Newark,  N.  J 232,  370 

New  Haven,  Conn 140,  219,  370 

New  Haven  jail 191 

Newport,  R.  I ■  .    185,  220,  370 

New  York  City 121,  122,  123,  124,  254 


INDEX.  403 

PAGE 

New  York  Department  of  Health 317 

Northwest,  epidemic  on  Steamer 180,  212 

Nostrums 91 

Nurse,  duty  of      24 

Occupation 112 

Ogdensburg  hospital 208 

Ohio  River 265 

Oysters      66,  80 

Oysters,  epidemics  due  to 136,  204,  206 

Oxidation  in  streams 55 

Panama * 196 

Parasites 14 

Parathyphoid  fever 7 

Paris,  France 243,  394 

Parker,  Horatio  N 190 

Passaic  River 232,  242 

Pasteurized  milk 79,  87,  267 

Paterson,  X.  J 242,  370 

Pearse,  Langdon 154 

Pease,  Dr.  H.  D 344 

Penobscot  River 178,  263 

Personal  responsibility 89 

Perspiration 19 

Peyer^s  patches 12 

Phelps,  Prof.  Earle  B 187 

Philadelphia,  Pa 77,  122,  246,  370 

Phihppine  Islands,  t}-phoid  fever  in 117,  118 

Physician,  dut\'  of 23 

Pipes,  purification  of  water  in 60 

Pittsburg,  Pa 122,  15S,  283,  367,  370 

Plymouth,  Pa 136,  370 

Pollution  of  streams 263 

Population,  estimation  of 303 

Portals  of  entr)- 12 

Port  Deposit,  Md 209 

Portland,  Me 130 

Potomac  River 120,  1S9,  265 

Poughkeepsie,  X.  Y 260,  370 


404  INDEX. 

PAGE 

Prescott  and  Winslow 332 

President's  message 361 

Price,  Dr.  M.  L 190 

Public  authorities 34,  70 

Pure  water,  value  of 273 

Quarantine 33 

Race no 

Railroad  car  toilet  rooms 38 

Registration  area 112 

Rennes,  France 208 

Report  to  Board  of  Health 26,  34,  70 

Residual  typhoid  fever 132 

Resistant  minority 47,  52,  213 

Richmond,  Va 154,  156 

Roosevelt,  President 361 

Rosenau,  Dr.  M.  J ■ 2151 

Rural      112,  215,  371 


Saliva 19 

San  Francisco,  Cal 124 

Sanitary  supervision  of  watersheds 75 

Sanitiage  de  Chile 124 

Savage 332 

Schenectady,  N.  Y 263 

Schuylkill  River ' 246 

Scranton,  Pa 145,  371 

Screens 32,  87 

Seaman,  Dr.  Louis  L 198,  362 

Seasonal  distribution 121,  126 

Sedimentation 54,  57 

Sedgwick,  Prof.  William  T 61,  125,  150,  199,  251 

Self-purification  of  lakes  and  reservoirs 56 

Self-purification  of  streams 53,  56 

Sewage  disposal 36 

Sewage,  longevity  of  the  typhoid  bacillus 50,  51 

Sewage  purification      52,  265 

Sewer  gas 36,  43 


INDEX.  405 

PAGE 
■5^^ • 109 

Shenandoah  Valley 120 

Shiga  bacillus ^ 

Smith,  Herbert  E 140,  191,  202 

Soil  bacteria      54 

Soil,  typhoid  bacillus  in      6^ 

Somerville,  Mass 108,  220 

Soper,  Dr.  Geo.  A 142,  174,  207 

South  America,  typhoid  fever no 

Southampton,  England 2015 

South-end,  London 209 

Southern  states 114,  11  c    2?o 

Spanish  War 129,  195,  214,  256,  258 

Spleen ^ 

Springfield,  Mass 76,199,207,371 

Spring  waters ^g 

Stagnation  of  lakes ry 

Stamford,  Conn 108,  142,  201,  371 

Standards  of  purity - . 

Statistics 71,  92,  98 

St.  Louis,  Mo loj^  24^ 

Sterilization 288 

Storage,  effect  on  quality  of  water ';8    eg 

Sunlight '44 

Surface  waters » - 

Susquehanna  River 261; 

Switzerland,  Lausen jgj 

Symptoms ^^  2^ 

Taylor,  L.  H j,^ 

Temperature,  effect  on  typhoid  bacillus 4c 

Temperature  of  body  in  typhoid  fever , 

Time,  influence  on  longevity  of  B.  typhi ee 

Tobacco Q 

Toilet  rooms _„ 

Traveling,  risks  of qq 

Treatment  of  typhoid  fever e    24 

Trenton,  N.  J ^gg 

Troy,  N.  Y 276 

Typhoid  bacillus      8,  314,  322,  332,  337,  344 


406  INDEX. 

PAGE 

Typhoid  bacillus  at  large 41 

Typhoid  carriers '. 19 

Typhoid  fever,  typical  case 2 

Typhoid  Mary 20 

Typho-toxin 15 

United  States  army  camps 195,  356,  362,  37 

United  States,  cost  of  typhoid  fever 275 

United  States  Navy 196 

Urban  typhoid 112 

Urine  affected  in  typhoid  fever 18,  24,  294,  320 

Urotropin 24,  294 

Vacation  typhoid 127 

Value  of  human  life 273 

Value  of  pure  water 273 

Vehicles  of  infection 22,  84 

Vended  waters      78 

Viability  of  typhoid  bacillus 46,  344 

'  Vienna 394 

Wainright,  Dr 147 

Walking  cases ■ 6,  20 

Warnings  of  epidemics 211 

Washington,  D.  C 112,  122,  127,  191,  248,  270,371 

Water  analyses 76,  222,332,337 

Waterbury,  Conn 76,  202 

Water  cresses 209 

Water,  epidemics  due  to 13S)  228 

Water  filtration 73-265 

Water,  longevity  of  typhoid 46 

Water  supplies 72,  74,  221,  228 

Watertown,  N.  Y 77,  242,  280,  371 

Waterville,  Me 108,  154,  371 

Waves  of  typhoid 265 

Well  water 85 

Wesleyan  University 204 

Widal  test •    -    •       16,  317 

Williams  College 208,  371 

Winchester,  England ■ 205 


INDEX.  407 


PAGE 


Wing,  Frank  E 367 

Winnipeg,  ^lanitoba 102,  220,  -571 

Winslow,  Prof.  C.  E.  A 61,  125,  185 

Youngstown,  Ohio 249 


Zinc,  chloride 


294 


Zurich,  Switzerland 235 


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*  Laboratory  Manual  for  Students i2mo,    1  00 

Holleman's  Text-book  of  Inorganic  Chemistry.     (Cooper.) Svo,    2  50 

Text-book  of  Organic  Chemistry.     (Walker  and  Mott.) Svo,    2  50 

*  Laboratory  Manual  of  Organic  Chemistry.     (Walker.) i2mo,     i  00 

4 


HoUey  and  Ladd's  Analysis  oi  Mixed  Paints,  Color  Pigments .  and  Varnishes. 
(InPres;; 

Hopkins's  Oil-chemists'  Handbook 8vo,    3  00 

Iddings's  Rock  Minerals  . 8vo,    5  00 

Jackson's  Directions  for  Laboratory  Work  in  Physiological  Chemistry.  .8vo,  i  25 
Johannsen's  Key  for  the  Determination  of  Rock-forming  Minerals  in  Thin  Sec- 
tions.      In  Press) 

Keep's  Cast  Iron 8vo,  2  50 

Ladd's  Manual  of  Quantitative  Chemical  Analysis i2mo,  i  00 

Landauer's  Spectrum  Analysis.     (Tingle.) Svo,  3  00 

*  Langworthy    and   Austen.         The   Occurrence    of   Aluminium   in   Vegetable 

Products,  Animal  Products,  and  Natural  Waters 8vo,  2  00 

Lassar-Cohn's  Apphcation  of  Some  General  Reactions   to  Investigations  in 

Organic  Chemistry.      (Tingle. ; i2mo,  i   00 

Leach's  The  Inspection  and  Analysis  of  Food  with  Special  Reference  to  State 

Control Svo,  7  50 

Lob's  Electrochemistry  of  Organic  Compounds.     (Lorenz.) Svo,  3  00 

Lodge's  Notes  on  Assaying  and  Metallurgical  Laboratory  Experiments.  ..  .8vo,  3  00 

Low's  Technical  Method  of  Ore  Analysis Svo,  3  00 

Lunge's  Techno-chemical  Analysis.      (Cohn.) i2mo  i  00 

*  McKay  and  Larsen's  Principles  and  Practice  of  Butter-making Svo,  i  50 

Maire's  Modem  Pigments  and  their  vehicles.     '  In  Press.) 

Mandel's  Handbook  for  Bio-chemical  Laboratory i2mo,  i  50 

*  Martin's  Laboratory  Guide  to  Qualitative  Analysis  with  the  Blowpipe .  .  i2mo,  60 
Mason's  Water-supply.     '  Considered  Principally  from  a  Sanitary  Standpoint. ) 

3d  Edition,  Rewritten Svo,  4  00 

Examination  of  Water.     (Chemical  and  BacteriologicaL) i2mo,  1  25 

Matthew's  The  Textile  Fibres.     2d  Edition,  Rewritten  - Svo,  400 

Meyer's  Determination  of  Radicles  in  Carbon  Compounds.     (Tingle.).  .i2mo,  i  00 

Miller's  Manual  of  Assaying i2mo,  i   00 

Cyanide  Process   i2nio,  i   00 

Minet's  Production  of  Aluminum  and  its  Industrial  Use.     (Waldo.) ....  i2mo,  2  50 

Mixter's  Elementary  Text-book  of  Chemistry i2mo,  i  50 

Morgan's  An  Outline  of  the  Theory  of  Solutions  and  its  Results i2mo,  i  00 

Elements  of  Physical  Chemistry i2ino,  3  00 

*  Physical  Chemistry  for  Electrical  Engineers i2mo,  5  00 

Morse's  Calculations  used  in  Cane-sugar  Factories i6mo,  morocco,  i  50 

*  Mu'r's  H'story  of  Chemical  Theories  and  Laws Svo,  4  00 

MulHken's  General  Method  for  the  Identification  of  Pure  Organic  Compounds. 

VoL  I Large  Svo,  5  00 

O'DriscoU's  Notes  on  the  Treatment  of  Gold  Ores 8vo,  2  00 

Ostwald's  Conversations  on  Chemistry.     Part  One.     (Ramsey.) i2mo,  i  50 

"                    "               "           "             Part  Two.     (TumbtilL) i2mo,  2  00 

*  Palmer's  Practical  Test  Book  of  Chemistry l2mo,  l  00 

*  PauU's  Physical  Chemistry  in  the  Service  of  Medicine.     (Fischer. '  ...  -  lamo,  i  25 

*  Penfield's  Notes  on  Determinative  Mineralogy  and  Record  of  Mineral  Tests. 

Svo,  paper,  50 

Pictet's  The  Alkaloids  and  their  Chemical  Constitution.     (Biddle.) Svo,  5  00 

Pinner's  Introduction  to  Organic  Chemistry.     (Austen.) i2mo,  i  50 

Poole's  Calorific  Power  of  Fuels Svo,  3  00 

Prescott  and  Winslow's  Elements  of  Water  Bacteriology,  with  Special  Refer- 
ence to  Sanitary  Water  Analysis i2nio,  i  25 

*  Reisig's  Guide  to  Piece-dyeing Svo,  25  00 

Richards  and  Woodman's  Air,  Water,  and  Food  from  a  Sanitary  Standpoint.. Svo,  2  00 

Ricketts  and  Miller's  Notes  on  Assaying Svo,  3  00 

Rideal's  Sewage  and  the  Bacterial  Purification  of  Sewage .Svo,  4  00 

Disinfection  and  the  Preservation  of  Food Svo,  4  00 

Riggs's  Elementary  Manual  for  the  Chemical  Laboratory Svo,  i  25 

Robine  and  Lenglen's  Cyanide  Industry.     (Le  Clerc.) Svo,  4  00 

5 


Ruddiman's  Incompatibilities  in  Prescriptions 8vo, 

*  Whys  in  Pharmacy i2mo, 

Sabin's  Industrial  and  Artistic  Technology  of  Paints  and  Varnish ,  .  .8voi 

Salkowski's  Physiological  and  Pathological  Chemistry.     (Orndorff.).  ..  .  .  .8vo, 

Schimpf 's  Text-book  of  Volumetric  Analysis i2ino. 

Essentials  of  Volumetric  Analysis. lamo, 

*  Qualitative  Chemical  Analysis 8vo, 

Smith's  Lecture  Notes  on  Chemistry  for  Dental  Students 8vo, 

Spencer's  Handbook  for  Chemists  of  Beet-sugar  Houses i6mo,  morocco 

Handbook  for  Cane  Sugar  Manufacturers i6mo,  morocco, 

Stockbridge's  Rocks  and  Soils 8vo, 

*  Tillman's  Elementary  Lessons  in  Heat 8vo, 

*  Descriptive  General  Chemistry 8voi 

Treadwell's  Qualitative  Analysis.     (Hall.) • 8vOr 

Quantitative  Analysis.     (Hall.) 8vo, 

Turneaure  and  Russell's  PubUc  Water-supplies 8vo, 

Van  Deventer's  Physical  Chemistry  for  Beginners.     (Boltwood.) i2mo, 

*  Walke's  Lectures  on  Explosives 8vo, 

Ware's  Beet-sugar  Manufacture  and  Refining.     VoL  I Small  8vo, 

Vol.  II SmallSvo, 

Washington's  Manual  of  the  Chemical  Analysis  of  Rocks 8vo, 

Weaver's  Military  Explosives - 8vo, 

Wehrenfennig's  Analysis  and  Softening  of  Boiler  Feed-Water Bvo, 

Wells's  Laboratory  Guide  in«Qualitative  Chemical  Analysis 8vo, 

Short  Course  in  Inorganic  Qualitative  Chemical  Analysis  for  Engineering 

Students i2mo. 

Text-book  of  Chemical  Arithmetic ; i2mo, 

Whipple's  Microscopy  of  Drinking-water 8vo, 

Wilson's  Cyanide  Processes i2mo, 

Chlorination  Process.  , i2rno, 

V/inton's  Microscopy  of  Vegetable  Foods 8vo, 

WuUing's    Elementary    Course    in  Inor^auic,  Pharmaceutical,  and  Medical 
Chemistry i2mo. 


CIVIL  ENGINEERING. 

BRIDGES    AND    ROOFS.       HYDRAULICS.       MATERIALS    OF    ENGINEERING 
RAILWAY   ENGINEERING. 

Baker's  Engineers'  Surveying  Instruments i2mo,  3  oa 

Bixby's  Graphical  Computing  Table Paper  igj  X24i  inches.  25 

Breed  and  Hosmer's  Principles  and  Practice  of  Surveying 8vo,  3  00 

*  Burr's  Ancient  and  Modern  Engineering  and  the  Isthmian  Canal 8vo,  3  50 

Comstock's  Field  Astronomy  for  Engineers 8vo,  2  50 

*  CortheU's  AUov7able  Pressures  on  Deep  Foundations l2mo,  i  25 

Crandall's  Text-book  on  Geodesy  and  Least  Squares 8vo,  3  00 

Davis's  Elevation  and  Stadia  Tables 8vo,  i   00 

ElHott's  Engineering  for  Land  Drainage i2mo,  i   50 

Practical  Farm  Drainage i2mo,  i  00 

*Fiebeger's  Treatise  on  Civil  Engineering 8vo,  5  00 

Flemer's  Phototopographic  Methods  and  Instruments 8vo,  5  00 

Folwell's  Sewerage.     (Designing  and  Maintenance.) 8vo,  3  00 

Freitag's  Architectural  Engineering.     2d  Edition,  Rewritten 8vo,  3  50 

French  and  Ives's  Stereotomy 8vo,  2  50 

Goodhue's  Municipal  Improvements i2mo,  i   50 

Gore's  Elements  of  Geodesy 8vo,  2  50 

*  Hauch  and  Rice's  Tables  of  Quantities  for  Preliminary  Estimates, l2mo,  i  25 

Hayford's  Text-book  of  Geodetic  Astronomy 8vo,  3  00 

6 


2 

50 

I 

25 

I 

25 

2 

50 

3 

00 

3 

00 

2 

50 

I 

50 

3 

00 

3 

00 

4 

00 

5 

00 

1 

50 

4 

00 

4 

00 

5 

CO 

2 

00 

3 

00 

A 

00 

i 

50 

50 

25 

50 

50 

5C 

50 

Bering's  Ready  Reference  Tables  (Conversion  Factors) i6mo,  morocco, 

Howe's  Retaining  Walls  for  Earth i2mo, 

Hoyt  and  Grover's  River  Discharge 8vo, 

*  Ives's  Adjustments  of  the  Engineer's  Transit  and  Level i6mo,  Bds. 

Ives  and  Hilts's  Problems  in  Surveying i6mo,  morocco, 

Johnson's  (J.  B. )  Theory  and  Practice  of  Surveying Small  8vo, 

Johnson's  (L.  J.)  Statics  by  Algebraic  and  Graphic  Methods 8vo, 

Laplace's  Philosophical  Essay  on  Probabilities.     (Truscott  and  Emory.) .  i2mo, 
Mahan's  Treatise  on  Civil  Engineering.     (1873.J     (Wood.) 8vo, 

*  Descriptive  Geometry 8vo, 

Merriman's  Elements  of  Precise  Surveying  and  Geodesy. 8vo, 

Merriman  and  Brooks's  Handbook  for  Surveyors i6mo,  morocco, 

Nugent's  Plane  Surveying 8vo, 

Ogden's  Sewer  Design.  . l2mo, 

Parsons's  Disposal  of  Municipal  Refuse.  ^ 8vo, 

Patton's  Treatise  on  Civil  Engineering 8vo  half  leather. 

Reed's  Topographical  Drawing  and  Sketching 4to, 

Rideal's  Sewage  and  the  Bacterial  Purification  of  Sewage 8vo, 

Riemer's  Shaft-sinking  under  Difficult  Conditions.     (Coming  and  Peele.) .  .8vo, 

Siebert  and  Biggin's  Modern  Stone-cuttmg  and  Masonry 8vo, 

Smith's  Manual  of  Topographical  Drawing.      'McMillan.) 8vo, 

Sondericker's  Graphic  Statics,  with  Applications  to  Trusses,  Beams,  and  Arches. 

8vo, 

Taylor  and  Thompson's  Treatise  on  Concrete,  Plain  and  Reinforced 8vo, 

Tracy's  Plane  Surveying i6mo,  morocco, 

*  Trautwine's  Civil  Engineer's  Pocket-book i6mo,  morocco, 

Venable's  Garbage  Crematories  in  America 8vo, 

Wait's  Engineering  and  Architectural  Jurisprudence 8vo, 

Sheep, 
Law  of  Operations  Preliminary  to  Construction  in  Engineering  and  Archi- 
tecture  8vo, 

Sheep, 

Law  of  Contracts. 8vo, 

Warren's  Stereotomy — Problems  in  Stone-cutting 8vo,    2  50 

Webb's  Problems  in  the  Use  and  Adjustment  of  Engineering  Instruments. 

i6mo,  morocco,     i   23 
Wilson's  Topographic  Surveying 8vo,    3  50 

BRIDGES  AND   ROOFS. 

BoUer's  Practical  Treatise  on  the  Construction  of  Iron  Highway  Bridges.  .8vo,  2  00 

Burr  and  Falk's  Influence  Lines  for  Bridge  and  Roof  Computations 8vo,  3  00 

Design  and  Construction  of  MetaUic  Bridges 8vo,  5  00 

Du  Bois's  Mechanics  of  Engineering.     VoL  U Small  4to,  10  co 

Foster's  Treatise  on  Wooden  Trestle  Bridges 4to,  5  00 

Fowler's  Ordinary  Foundations 8vo,  3  50 

Greene's  Roof  Trusses 8vo,  1  25 

Bridge  Trusses 8vo,  2  50 

Arches  in  Wood,  Iron,  and  Stone Svo^  2  50 

(Grimm's  Secondary  Stresses  in  Bridge  Trusses.     (In  Press.) 

Howe's  Treatise  on  Arches 8vo,  4  00 

Design  of  Simple  Roof-trusses  in  Wood  and  SteeL 8vo,  2  00 

Symmetrical  Masonry  Arches 8vo,  2  50 

Johnson,  Bryan,  and  Turneaure's  Theory  and  Practice  in  the  Designing  of 

Modem  Framed  Structures Small  4to,  10  00 

Merriman  and  Jacoby's  Text-book  on  Roofs  and  Bridges; 

Part  I.     Stresses  in  Simple  Trusses 8vo,  2  50 

Part  n.     Graphic  Statics 8vo,  2  50 

Part  in.  Bridge  Design .  8vo,  2  50 

Part  TV.   Higher  Structures Bvo,  2  50 

7 


7 

50 

5 

00 

4 

00 

3 

00 

1 

50 

2 

50 

2 

00 

5 

00 

3 

00 

5 

00 

2 

00 

6 

00 

6 

50 

5 

00 

5 

50 

3 

00 

Morison's  Memphis  Bridge.    4to,  lo  oo 

Waddell's  De  Pontibus,  a  Pocket-book  for  Bridge  Engineers .  .  i6mo,  morocco,  2  00 

*  Specifications  for  Steel  Bridges i2mo,  50 

Wright's  Designing  of  Draw-spans,     Two  parts  in  one  volume 8vo,  3  50 

HYDRAULICS. 

Barnes's  Ice  Formation 8vo,  3  00 

Bazin's  Experiments  upon  the  Contraction  of  the  Liquid  Vein  Issuing  from 

an  Orifice.     (Trautwine.) 8vo,  2  00 

Bovey's  Treatise  on  Hydraulics 8vo,  5  00 

Chxirch's  Mechanics  of  Engineering 8vo,  6  00 

Diagrams  of  Mean  Velocity  of  Water  in  Open  Channels paper,  i  50 

Hydraulic  Motors 8vo,  2   00 

Coffin's  Graphical  Solution  of  Hydraulic  Problems i6mo,  morocco,  2  50 

Flather's  Dynamometers,  and  the  Measurement  of  Power i2mo,  3  00 

Folwell's  Water-supply  Engineering 8vo,  4  00 

Frizell's  Water-power 8vo,  5  00 

Fuertes's  Water  and  Public  Health i2mo.  1  50 

Water-filtration  Works i2mo.  2  50 

GanguiUet  and  Kutter's  General  Formula  for  the  Uniform  Flow  of  Water  m 

Rivers  and  Other  Channels.      (Hering  and  Trautwine.) 8vo,  4  00 

Hazen's  Clean  Water  and  How  to  Get  It Large  l2mo,  1  5o 

Filtration  of  Public  Water-supply 8vo,  3  00 

Hazlehurst's  Towers  and  Tanks  for  Water- works 8vo,  2  50 

Herschel's  115  Experiments  on  the  Carrying  Capacity  of  Large,  Riveted,  Metal 

Conduits 8vo,  2  00 

*  Hubbard  and  Kiersted's  Water-works  Management  and  Maintenance. .  .  8vo,  4  co 
Mason's  Water-supply.     (Considered  Principally  from  a  Sanitary  Standpoint.) 

8vo,  4  00 

Merriman's  Treatise  on  Hydraulics.  . 8vo,  5  00 

*  Michie's  Elements  of  Analytical  Mechanics 8vo,  4  00 

Schuyler's   Reservoirs   for   Irrigation,    Water-power,   and   Domestic   Water- 
supply Large  8vo,  5  00 

*  Thomas  and  Watt's  Improvement  of  Rivers 4to,  6  00 

Tumeaure  and  Russell's  Public  Water-supplies 8vo,  5  00 

Wegmann's  Design  and  Construction  of  Dams.     5th  Edition,  enlarged.  .  .4to,  6  00 

Water-supply  of  the  City  of  New  York  from  1658  to  1895 4to,  10  00 

Whipple's  Value  of  Pure  Water Large  i2mo,  i  00 

Williams  and  Hazen's  Hydraulic  Tables 8vo,  i  50 

Wilson's  Irrigation  Engineering Small  8vo,  4  00 

Wolff's  Windmill  as  a  Prime  Mover 8vo,  3  00 

Wood's  Turbines Bvo,  2   50 

Elements  of  Analytical  Mechanics 8vo,  3  00 


MATERIALS  OF  ENGINEERING. 

Baker's  Treatise  on  Masonry  Construction 8vo,  5  00 

Roads  and  Pavements 8vo,  5  00 

Black's  United  States  Public  Works Oblong  4to,  5  00 

*  Bovey's  Strength  of  Materials  and  Theory  of  Structures 8vo,  7  50 

Burr's  Elasticity  and  Resistance  of  the  Materials  of  Engineering 8vo,  7  50 

Byrne's  Highway  Construction 8vo,  5  00 

Inspection  of  the  Materials  and  Workmanship  Employed  in  Construction. 

i6mo,  3  00 

Church's  Mechanics  of  Engineering 8vo,  6  00 

Du  Bois's  Mechanics  of  Engineering.     Vol.  I Small  4to  7  50 

*Eckers  Cements,  Limes,  and  Plasters 8vo,  6  00 


Johnson's  Materials  of  Construction. Large  8vo,  6  oo 

Fowler's  Ordinary  Foundations 8vo,  3  50 

Graves's  Forest  Mensuration 8vo,  4  00 

*  Greene's  Structural  Mechanics 8vo,  2  50 

Keep's  Cast  Iron. 8vo,  2  so 

Lanza's  Applied  Meclianics 8vo,  7  50 

Martens's  Handbook  on  Testing  Materials.     (Henning.)     2  vols 8vp,  7  50 

Maurer's  Technical  Mechanics 8vo,  4  00 

Merrill's  Stones  for  Building  and  Decoration 8vo,  3  00 

Merriman's  Mechanics  of  Materials 8vo,  5  00 

*  Strength  of  Materials i2mo,  ■  i  00 

Metcalf's  Steel.     A  3Ianual  for  Steel-users i2mo,  2   00 

Patton's  Practical  Treatise  on  Foundations 8v0)  5  00 

Richardson's  Modern  Asphalt  Pavements 8vo,  3   00 

Richey's  Handbook  for  Superintendents  of  Construction i6mo,  mor.,  4  00 

*  Ries's  Clays:  Their  Occurrence.  Properties,  and  Uses. 8vo,  5  00 

Rockwell's  Roads  and  Pavements  in  France i2mo,  i   25 

Sabin's  Industrial  and  Artistic  Technology  of  Paints  ar-i  Varnish 8vo,  3  00 

♦Schwarz's  Long-ieaf  Pine  in  Virgin  Forest  ., lamo.  i    25 

Smith's  Materials  of  Machines i2mo,  i   00 

Snow's  Principal  Species  of  Wood 8vo,  3  50 

Spalding's  Hydraulic  Cement i2ino,  2  00 

Text-book  on  Roads  and  Pavements i2mo,  2  00 

Taylor  and  Thompson's  Treatise  on  Concrete,  Plain  and  Reinforced 8vo,  s  00 

Thurston's  Materials  of  Engineering.     3  Parts 8vo,  8  00 

Part  L     Non-metaUic  Materials  of  Engineering  and  Metallurgy 8vo,  2  00 

Part  n.     Iron  and  SteeL 8vo,  3  50 

Part  m.     A  Treatise  on  Brasses,  Bronzes,  and  Other  Alloys  and  their 

Constituents 8vo ,  250 

TiUson's  Street  Pavements  and  Paving  Materials.  , 8vo,  4  00 

Tuxneaure  and  J-Iaurer's  Principles  of  Reinforced  Concrete   Constmction-     Svo,  3  00 

Waddell's  De  Pontibus.      A  Pocket-book  for  Bridge  Engineers.   .  .  i6mo.  r::or.,  2  00 

*  Specifications  for  Steel  Bridges i2mo,  50 

Wood's  (De  V.I  Treatise  on  the  Resistance  of  Materials,  and  an  Appendix  on 

the  Preservation  of  Timber Svo,  2  00 

Wood's  CDe  V. )  Elements  of  Analytical  Mechanics 8vo,  3  00 

Wood's  (M.  P.  1  Rustless  Coatings:    Corrosion  and  Electrolysis  of  Iron  and 

SteeL 8vo,  4  00 


RAILWAY   ENGINEERING. 

Andrew's  Handbook  for  Street  Railway  Engineers 3x5  inches,  morocco,  i  25 

Berg's  Buildings  and  Structures  of  American  Railroads 4.to,  5  00 

Brook's  Handbook  of  Street  Railroad  Location i6nio,  morocco,  i   50 

Butt's  Civil  Engineer's  Field-book i6mo,  morocco,  2   50 

Crandall's  Transition  Ctirve i6mo,  morocco,  i  50 

Railway  and  Other  Earthwork  Tables Svo,  i  50 

Crookel:t's  Methods  for  Earthwork  Ccmputatioris.     (In  Press. 

Dawson's  "Engineering"  and  Electric  Traction  Pocket-book.    i6mo.  morocco  5   00 

Dredge's  History  of  the  Pennsylvania  Railroad:    (1879" Paper,  5  00 

Fisher's  Table  of  Cubic  Yards Cardboard,  23 

Godwin's  Railroad  Engineers'  Field-book  and  Explorers'  Guide.  .  .  i6mo,  mor.,  2  50 
Hudson's  Tables  for  Calculating  the  Cubic  Contents  of  Excavations  and  Em- 
bankments  8vo,  I   00 

MoUtor  and  Beard's  Manual  for  Resident  Engineers i6mo,  1  00 

Nagle's  Field  Manual  for  Railroad  Engineers i6mo,  morocco,  3  00 

Philbrick's  Field  Manual  for  Engineers r6mo,  morocco,  3  00 

Raymond's  Elements  of  Railroad  Engineering.      'In   Press.; 


Searles's  Field  Engineering i6mo,  morocco,  3  00 

Railroad  Spiral i6nio,  morocco,  x  50 

Taylor's  Prismoidal  Formulae  and  Earthwork 8vo,  i  50 

*  Trautwine's  Method  of  Calculating  the  Cube  Contents  of  Excavations  and 

Embankments  by  the  Aid  of  Diagrams 8vo,  2  00 

The  Field  Practice  of  Laying  Out  Circular  Cvirves  for  Railroads. 

i2mo,  morocco,  2  50 

Cross-section  Sheet Paper,  25 

Webb's  Railroad  Construction , i6mo,  morocco,  5  00 

Economics  of  Railroad  Construction Large  i2mo,  2  50 

Wellington's  Economic  Theory  of  the  Location  of  Railways.  ......  Small  8vo,,  5  00 


DRAWING. 

Barr's  Kinematics  of  Machinery Svo,  2  50 

*  Bartlett's  Mechariical  Drawing Svo,  3  00 

*  "                    "                    "       Abridged  Ed Svo,  1  so 

Coolidge's  Manual  of  Drawing Svo,  paper,  i  00 

Coolidge  and  Freeman's  Elements  of  General  Drafting  for  Mechanical  Engi- 
neers  Oblong  4t0)  2  so 

Durley's  Kinematics  of  Machines Svo,  4  00 

Emch's  Introduction  to  Projective  Geometry  and  its  Applications..  ..... .Svo,  2  50 

Hill's  Text-book  on  Shades  and  Shadows,  and  Perspective Svo,  2  00 

Jamison's  Elements  of  Mechanical  Drawing Svo,  2  50 

Advanced  Mechanical  Drawing Svo,  2  00 

Jones's  Machine  Design: 

Part  I.     Kinematics  of  Machinery. Svo,  i  50 

Part  II.     Form,  Strength,  and  Proportions  of  Parts Svo, 

MacCord's  Elements  of  Descriptive  Geometry Svo, 

Kinematics;  or.  Practical  Mechanism Svo, 

Mechanical  Drawing 4to, 

Velocity  Diagrams Svo, 

MacLeod's  Descriptive  Geometry Small  Svo, 

*  Mahan's  Descriptive  Geometry  and  Stone-cutting Svo, 

Industrial  Drawing.     (Thompson.) Svo, 

Moyer's  Descriptive  Geometry Svo,  2  00 

Reed's  Topographical  Drawing  and  Sketching 4to,  s  00 

Reid's  Course  in  Mechanical  Drawing Svo,  2  00 

Text-book  of  Mechanical  Drawing  and  Elementary  Machine  Design. Svo,  3  00 

Robinson's  Principles  of  Mechanism Svo,  3  00 

Schwamb  and  Merrill's  Elements  of  Mechanism Svo,  3  00 

Smith's  (R.  S.)  Manual  of  Topographical  Drawing.     (McMillan.) Svo,  2  50 

Smith  (A.  W.)  and  Marx's  Machine  Design. Svo,  3  00 

*  Titsworth's  Elements  of  Mechanical  Drawing Oblong  Svo,  i  25 

Warren's  Elements  of  Plane  and  Solid  Free-hand  Geometrical  Drawing.  i2mo,  i  00 

Drafting  Instruments  and  Operations i2mo,  1  25 

Manual  of  Elementary  Projection  Drawing i2mo,  i  50 

Manual  of  Elementary  Problems  in  the  Linear  Perspective  of  Form  and 

Shadow i2mo,  i  00 

Plane  Problems  in  Elementary  Geometry i2mo,  125 

Elements  of  Descriptive  Geometry,  Shadows,  and  Perspective Svo,  3  50 

General  Problems  of  Shades  and  Shadows Svo,  3  00 

Elements  of  Machine  Construction  and  Drawing Svo,  7  50 

Problems,  Theorems,  and  Examples  in  Descriptive  Geometry Svo,  2  50 

Weisbach's    Kinematics    and    Power    of    Transmission.        (Hermann    and 

Klein.) Svo,  5  Oq 

Whelpley's  Practical  Instruction  in  the  Art  of  Letter  Engraving i2mo,  2  oo 

Wilson's  (H.  M.)  Topographic  Surveying Svo,  3  50 

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Wilson's  (V.  T.)  Free-hand  Perspective 8vo,    2  50 

Wilson's  (V.  T.)  Free-hand  Lettering 8vo,     i  00 

Woolf's  Elementary  Course  in  Descriptive  Geometry Large  8vo,    3  00 

ELECTRICITY  AND   PHYSICS. 

*  Abegg's  Theory  of  Electrolytic  Dissociation.     (Von  Ende.) i2mo, 

Anthony  and  Brackett's  Text-book  of  Physics.     (Magie.) Small  Svo, 

Anthony's  Lecture-notes  on  the  Theory  of  Electrical  Measurements.  .  .  .12010, 
Benjamin's  History  of  Electricity Svo, 

Voltaic  Cell Svo. 

Betts's  Lead  Refining  and  Electrolysis.     (In  Press.) 

Classen's  Quantitative  Chemical  Analysis  by  Electrolysis.     (Boltwood.).8vo, 

*  Collins's  Manual  of  Wireless  Telegraphy i2mo, 

Morocco, 
Crehore  and  Squier's  Polarizing  Photo-chronograph Svo, 

*  Danneel's  Electrochemistry.     (Merriam.) i2mo, 

Dawson's  "Engineering"  and  Electric  Traction  Pocket-book.  i6mo,  morocco, 
Dolezalek's  Theory  of  the  Lead  Accumulator  (Storage  Battery).    (Von  Ende.) 

i2mo, 

Duhem's  Thermodynamics  and  Chemistry.     (Burgess.) Svo, 

Flather's  Dynamometers,  and  the  Measurement  of  Power i2mo, 

Gilbert's  De  Magnete.     (Mottelay.) Svo, 

Hanchett's  Alternating  Currents  Explained i2mo, 

Bering's  Ready  Reference  Tables  (Conversion  Factors) lomo,  morocco, 

Hobart  and  Ellis's  High-speed  Dynamo  Electric  Machinery.     (In  Press.) 

Holman's  Precision  of  Measurements Svo,    2  00 

Telescopic   Mirror-scale  Method,  Adjustments,  and   Tests ....  Large  Svo,         75 
Karapetoff's  Experimental  Electrical  Engineering.     (In  Press.) 

Kinzbrunner's  Testing  of  Continuous-current  Machines Svo;    2  00 

Landauer's  Spectrum  Analysis.     (Tingle.) Svo,    3  00 

Le  Chatelier's  High-temperature  Measurements.  (Boudouard — Burgess.)  i2mo,    3  00 
Lob's  Electrochemistry  of  Organic  Compounds.     (Lorenz.) Svo,    3  00 

*  Lyons'3  Treatise  on  Electromagnetic  Phenomena.   Vols.  I.  and  II.  Svo,  each,    6  00 

*  Michie's  Elements  of  Wave  Motion  Relating  to  Sound  and  Light Svo,    4  00 

Niaudet's  Elementary  Treatise  on  Electric  Batteries.     (Fishback.) i2mo,    2  50 

Norris's  Introduction  to  the  Study   of  Electrical  Engineering.     (In  Press.) 

*  Parshall  and  Hobart's  Electric  Machine  Design 4to,  half  morocco,  12  50 

Reagan's  Locomotives:    Simple,  Compound,  and  Electric.      New  Edition. 

Large  12 mo,  3  50 

*  Rosenberg's  Electrical  Engineering.     (Haldane  Gee — Kinzbrunner.).  .  .8vo,  2  00 

Ryan,  Norris,  and  Hoxie's  Electrical  Machinery.     VoL  I Svo,  2  50 

Thurston's  Stationary  Steam-engines '.  ■  ■  Svo,  2  50 

*  Tillman's  Elementary  Lessons  in  Heat Svo,  i   50 

Tory  and  Pitcher's  Manual  of  Laboratory  Physics Small  Svo,  2  00 

Ulke's  Modern  Electrolytic  Copper  Refining Svo,  3  00 

LAW. 

*  Davis's  Elements  of  Law Svo,    2  50 

*  Treatise  on  the  MiUtary  Law  of  United  States Svo,    7  00 

*  Sheep,  7  50 
■''  Dudley's  Military  Law  and  the  Procedure  ol  Courts- martial  ...   Large  i2mo,  2  50 

Manual  for  Courts-martial i6mo,  morocco,  i  50 

Wait's  Engineering  and  Architectural  Jurisprudence.  ... Svo,  6  00 

Sheep,  6  50 
Law  of  Operations  Preliminary  to  Construction  in  Engineering  and  Archi- 
tecture  Svo  S  00 

Sheep,  5  50 

Law  of  Contracts 8vo,  3  00 

Winthrop's  Abridgment  of  Military  Law ' i2mo,  2  50 

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MANUFACTURES. 

Bemadou's  Smokeless  Powder — Nitro-cellulose  and  Theory  of  the  Cellulose 

Molecule i2nio, 

BoUand's  Iron  Founder i2mo, 

The  Iron  Founder,"  Supplement i2mo, 

Encyclopedia  of  Founding  and  Dictionary  of  Foundry  Terms  Used  in  the 
Practice  of  Moulding i2mo, 

*  Claassen's  Beet-sugar  Manufacture.    (Hall  and  Rolfe.) 8vo, 

*  Eckel's  Cements,  Limes,  and  Plasters 8vo, 

Eissler's  Modern  High  Explosives 8vo, 

Effront's  Enzymes  and  their  Applications.     (Prescott.) 8vo, 

Fitzgerald's  Boston  Machinist i2mo,     i  oo 

Ford's  Boiler  Making  for  Boiler  Makers i8mo.    i  oo 

Herrick's  Denatured  or  Industrial  Alcohol .8vo,    4   00 

Honey  and  Ladd's  Analysis  of  Mixed  Paints,  Color  Pigments,  and  Varnishes. 

(In  Presd.) 

Hopkins's  Oil-chemists'  Handbook 8vo,    3  00 

Keep's  Cast  Iron 8VO5    2  50 

Leach's  The  Inspection  and  Analysis  of  Food  with  Special  Reference  to  State 

Control Large  8vo,     7  50 

*  McKay  and  Larsen's  Principles  and  Practice  of  Butter-making 8vo,     i   50 

Maire's  Modem  Pigments  and  their  Vehicles.     (In  Press.) 

Matthews's  The  Textile  Fibres.     2d  Edition,  Rewritten 8vo,     4  00 

Metcalf's  Steel.     A  Maunal  for  Steel-users i2mo,     2  00 

Metcalfe's  Cost  of  Manufactures — And  the  Administration  of  Workshops  .  .  8vo, 

Meyer's  Modern  Locomotive  Construction 4to, 

Morse's  Calculations  used  in  Cane-sugar  Factories i6mo,  morocco, 

*  Reisig's  Guide  to  Piece-dyeing Svo, 

Rice's  Concrete-block  Manufacture 8vo, 

Sabin's  Industrial  and  Artistic  Technology  of  Paints  and  Varnish Svo, 

Smith's  Press-working  of  Metals Svo, 

Spalding's  Hydraulic  Cement i2mo, 

Spencer's  Handbook  for  Chemists  of  Beet-sugar  Houses i6mo,  morocco, 

Handbook  for  Cane  Sugar  Manufacturers i6mo,  morocco, 

Taylor  and  Thompson's  Treatise  on  Concrete,  Plain  and  Reinforced Svo, 

Thurston's  Manual  of  Steam-boilers,  their  Designs,  Construction  and  Opera- 
tion  Svo, 

Ware's  Beet-sugar  Manufacture  and  Refining.     Vol.  I Small  Svo, 

Vol.  II Svo, 

Weaver's  Military  Explosives Svo, 

West's  American  Foundry  Practice i2mo. 

Moulder's  Text-book i2mo, 

Wolff's  Windmill  as  a  Prime  Mover Svo, 

Wood's  Rustless  Coatings:   Corrosion  and  Electrolysis  of  Iron  and  Steel     Svo, 

MATHEMATICS. 

Baker's  EHiptic  Functions Svo,  i  50 

Briggs's  Elements  of  Plane  Analytic  Geometry i2mo,  i  00 

Buchanan's. Plane  and  Spherical  Trigonometry.     (In  Press.) 

Compton's  Manual  of  Logarithmic  Computations i2mo,  1  50 

Davis's  Introduction  to  the  Logic  of  Algebra Svo,  i  50 

*  Dickson's  College  Algebra Large  i2mo,  i  50 

*  Introduction  to  the  Theory  of  Algebraic  Equations Large  1 2mo,     1   25 

Emch's  Introduction  to  Projective  Geometry  and  its  Applications Svo,     2  50 

Halsted's  Elements  of  Geometry Svo,     1  75 

Elementary  Synthetic  Geometry Svo,     1   50 

*  Rational  Geometry i2mo,     I  SO 

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*  Jolin&on's  'J.  B.'  Three-place  Logarithmic  Tables:  Vest-pocket  size. paper, 

100  copies  for     5 

*  Mounted  on  beavv  caurdboaxd,  8X10  inches, 

10  copies  for     2   1 
Johnson's  I'W.  "W.)  Elementary  Treatise  on  Differential  Calculus     Small  8vo,     3 

Elementary  Treatise  on  the  Integral  Calculus Small  8vo,      i 

Johnson's    W.  W.,,  Curve  Tracing  in  Cartesian  Co-ordinates i2mo,      i 

Johnson's  (W.  W.)  Treatise  on  Ordinary  and  Partial  Differential  Equations. 

Small  8to,     3 

Johnson's  Treatise  on  the  Integral  Calculus Small  Svo,      3 

Johnson's    W.  W.'  Theory  of  Errors  and  the  Method  of  Least  Squares.  i2mo,     1 

*  Johnson's    W.  W.,'  Theoretical  Mechanics i2mo,     3 

Laplace's  Philosophical  Essay  on  Probabilities.     (Tniscott  and  Emory., .i2mo,     2 

*  Ludlow  and  Bass.     Elements  of  Trigonometry  and  Logarithmic  and  Other 

Tables Svo,     3  i 

Trigonometry  and  Tables  published  separately Each,     2  ' 

*  Ludlow's  Logarithmic  and  Trigonometric  Tables Svo,     i   • 

Manning's  IrrationaIN umbers  and  their  Representation  bySequences  and  Series 

i2mo,      I 
Mathematical  Monographs.     Edited  by  Mansfield  Merriman  and  Robert 

S.  Woodvrard Octavo,  each     i 

No.  1.  History  of  Modern  Mathematics,  by  David  Eugene  Smith. 
Kg.  2.  Synthetic  Projective  Geometry,  by  George  Bruce  Halsted. 
Ko.  3.  Determinants,  by  Laenas  Gift'ord  "Weld.  'So.  4.  Hyper- 
bolic Functions,  by  James  McMahon.  Ifo.  5.  HarmorJc  Func- 
tions, by  William.  E.  Byerly.  Uo.  6.  Grassmann's  Space  Analysis, 
by  Edward  W.  Hyde.  'So.  7.  Probabihty  and  Theory  of  Errors, 
by  Robert  S.  Woodward.  Ko.  8.  Vector  Analysis  and  Quaternions, 
by  Alexander  Macfarlane.  No.  9.  Differential  Equations,  by 
William  Woolsey  Johnson.  Ko.  10.  The  Solution  of  Eqiiations, 
by  Mansfield  Merriman.  JTo.  11.  Functions  of  a  Complex  Variable, 
by  Thomas  S.  Fiske. 

Maurer's  Technical  Mechanics Svo,    4  < 

Merriman's  Method  of  Least  Squares Svo,     2  < 

Rice  and  Johnson's  Elementary  Treatise  on  the  Differential  Calcxilus. .  Sm.  Svo,     3  ( 
Differential  and  Integral  Calculus.     2  vols,  in  one Small  Svo,     ■>.  ; 

*  Veblen  and  Lennes's  Introduction  to  the  Real  Infinitesimal  Analysis  of  One 

Variable Svo ,    2  < 

Wood's  Elements  of  Co-ordinate  Geometry Svo,     2  ( 

Trigonometry:    Analytical,  Plane,  and  Spherical i2mo,     i   < 

mecha:s'ical  e:s^gi:n"eerin&. 

ilATERIALS   OF   EXGIKEERIKG,   STEAM-E^'GIKES  AKD   BOILERS. 

Bacon's  Forge  Practice i2mo, 

Baldwin's  Steam  Heating  for  Buildings i2mo, 

Barr's  Kinematics  of  Machinery Svo, 

*  Bartlett's  Mechanical  Drawing Svo, 

*  '•  "  "        Abridged  Ed Svo, 

Benjamin's  Wrinkles  and  Recipes i2mo, 

Carpenter's  Experimental  Engineering Svo, 

Heating  and  Ventilating  Buildings Svo, 

Clerk's  Gas  and  Oil  Engine Small  Svo, 

Coolidee's  Manual  of  Drawing Svo,  paper, 

Coolidge  and  Freeman's  Elements  of  General  Drafting  for  Mechanical  En- 
gineers   Oblong  4to , 

Cromwe'l's  Treatise  on  Toothed  Gearing i2ino. 

Treatise  on  Belts  and  Pullevs i2mo, 

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Durley's  Kinematics  of  Machines 8vo,  4  00 

Flather's  Dynamometers  and  the  Measurement  of  Power. i2mo,  3  00 

Rope  Driving i2mo,  2  00 

Gill's  Gas  and  Fuel  Analysis  for  Engineers , i2mo,  i  25 

Hall's  Car  Lubrication i2mo,  i  00 

Bering's  Ready  Keference  Tables  (Conversion  Factors) i6mo,  morocco,  2  50 

Button's  The  Gas  Engine, 8vo,  s  00 

Jamison's  Mechanical  Drawing 8vo,  2  50 

Jones's  Machine  Design: 

Part  I.     Kinematics  of  Machinery " 8vo,  i  50 

Part  II.     Form,  Strength,  and  Proportions  of  Parts 8vo,  3  00 

Kent's  Mechanical  Engineers'  Pocket-book i6mo,  morocco,  5  00 

Kerr's  Power  and  Power  Transmission 8vo,  2  00 

Leonard's  Machine  Shop,  Tools,  and  Methods 8vo,  4  00 

*  Lorenz's  Modern  Refrigerating  Machinery.    (Pope,  Haven,  and  Dean.)  .  .  Svo,  4  00 
MacCord's  Kinematics;   or.  Practical  Mechanism Svo,  5  00 

Mechanical  Drawing 4to,  4  00 

Velocity  Diagrams Svo,  i  50 

MacFar land's  Standard  Reduction  Factors  for  Gases Svo,  i  50 

Mahan's  Industrial  Drawing.     (Thompson.) Svo,  3  50 

Poole's  Calorific  Power  of  Fuels , Svo,  3  00 

Reid's  Course  in  Mechanical  Drawing Svo,  2  00 

Text-book  of  Mechanical  Drawing  and  Elementary  Machine  Design. Svo,  3  00 

Richard's  Compressed  Air i2mo,  i  50 

Robinson's  Principles  of  Mechanism Svo,  3  00 

Schwamb  and  Merrill's  Elements  of  Mechanism Svo,  3  00 

Smith's  (O.)  Press- working  of  Metals Svo,  3  00 

Smith  (A.  W.)  and  Marx's  Machine  Design Svo,  3  00 

Thurston's   Treatise    on    Friction  and   Lost   Work   in   Machinery   and    Mill 

Work Svo,  3  00 

Animal  as  a  Machine  and  Prime  Motor,  and  the  Laws  of  Energetics.  1 2mo,  i  00 

Tillson's  Complete  Automobile  Instructor i6mo,  1  50 

Morocco,  2  00 

Warren's  Elements  of  Machine  Construction  and  Drawing Svo,  7  50 

Weisbach's    Kinematics    and    the    Power    of    Transmission.     (Herrmann — 

Klein.) Svo,  5  00 

Machinery  of  Transmission  and  Governors.     (Herrmann — Klein.).  .Svo,  5  00 

Wolff's  Windmill  as  a  Prime  Mover Svo,  3  00 

Wood's  Turbines Svo,  2  50 

MATERIALS   OF    ENGINEERING. 

*  Bovey's  Strength  of  Materials  and  Theory  of  Structures Svo,  7  50 

Burr's  Elasticity  and  Resistance  of  the  Materials  of  Engineering.     6th  Edition. 

Reset Svo,  7  50 

Church's  Mechanics  of  Engineering Svo,  6  00 

*  Greene's  Structural  Mechanics Svo,  2  50 

Johnson's  Materials  of  Construction Svo,  6  00 

Keep's  Cast  Iron Svo,  2  50 

Lanza's  Applied  Mechanics Svo,  7  50 

Martens's  Handbook  on  Testing  Materials.     (Henning.) Svo,  7  50 

Maurer's  Technical  Mechanics Svo,  4  00 

Merriman's  Mechanics  of  Materials Svo,  5  00 

*  Strength  of  Materials i2mo,  1  00 

Metcalf's  SteeL     A  Manual  for  Steel-users i2mo,  2  00 

Sabin's  Industrial  and  Artistic  Technology  of  Paints  and  Varnish Svo,  3  00 

Smith's  Materials  of  Machines i2mo,  i  00 

Thurston's  Materials  of  Engineering 3  vols.,  Svo,  8  00 

Part  II.     Iron  and  Steel Svo,  3  50 

Part  in.     A  Treatise  on  Brasses,  Bronzes,  and  Other  Alloys  and  their 

Constituents Svo,  2  50 

14 


Wood's  CDe  V.)  Treatise  on  the  Resistance  of  Materials  and  an  Appendix  on 

the  Preservation  of  Timber 8to,     2  00 

Elements  of  Analj^'cal  Mechanics 8vo,     3  00 

Wood's  CM.  P.)  Rustless  Coatings:    Corrosion  and  Electrolysis  of  Iron  and 

Steel 8vo ,    4  00 

STEAM-ENGINES   AND   BOILERS. 

Berry's  Temperature-entropy  Diagram. i2mo,    i  25 

Camot's  Reflections  on  the  Motive  Power  of  Heat.     (Thurston.) i2mo,    i  50 

Creighton's  Steam-engine  and  olher  Heat-motors. .  . Svo,    5  00 

Dawson's  "Engineering"  and  Electric  Traction  Pocket-book.  ,  .  .i6mo,  mor.,     5  00 

Ford's  Boiler  Making  for  Boiler  Makers iSmo,    i  00 

Goss's  Locomotive  Sparks Svo,    2  00 

Locomotive  Performance Svo,    5  00 

Hemenway's  Indicator  Practice  and  Steam-engine  Economy i2mo,     2  00 

Button's  Mechanical  Engineering  of  Power  Plants Svo,     5  00 

Heat  and  Heat-engines Svo,     5  00 

Kent's  Steam  boiler  Economy Svo,     4  00 

Kneass's  Practice  and  Theory  of  the  Injector Svo,    i  50 

MacCord's  SUde-valves Svo,     2  00 

Meyer's  Modem  Locomotive  Construction 4to,  10  00 

Peabody's  Manual  of  the  Steam-engine  Indicator i2mo,     i   50 

Tables  of  the  Properties  of  Saturated  Steam  and  Other  Vapors    Svo,     i   00 

Thermodynamics  of  the  Stsam-engine  and  Other  Heat-engines Svo,    5  00 

Valve-gears  for  Steam-engines Svo,    2  50 

Peabody  and  Miller's  Steam-boiiers Svo,    4  00 

Pray's  Twenty  Years  vrith  the  Indicator Large  Svo,     2  50 

Pupin's  Thermodynamics  of  Reversible  Cycles  in  Gases  and  Saturated  Vapors. 

(Osterberg. ' i2nio,     i   25 

Reagan's  Locomotives:    Simple,  Compound,  and  Electric.     New  Edition. 

Large  i2mo,    3  50 

Sinclair's  Locomotive  Engine  Running  and  Management i2nio,    2  00 

Smart's  Handbook  of  Engineering  Laboratory  Practice i2mo,    2  50 

Snow's  Steam-boiler  Practice Svo,    3  00 

Spangler's  Valve-gears Svo,     2  50 

Notes  on  Thermodynamics i2mo,     i   00 

Spangler,  Greene,  and  Marshall's  Elements  of  Steam-engineering Svo,    3  00 

Thomas's  Steam-turbines Svo,     3  50 

Thurston's  Handy  Tables Svo,     i  50 

Manual  of  the  Steam-engine 2  vols.,  Svo,  10  00 

Part  I.     History,  Structure,  and  Theory. Svo,    6  00 

Part  n.     Design,  Construction,  and  Operation Svo,    6  00 

Handbook  of  Engine  and  Boiler  Trials,  and  the  Use  of  the  Indicator  and 

the  Prony  Brake Svo,    5  00 

Stationary  Steam-engines Svo,    2  50 

Steam-boiler  Explosions  in  Theory  and  in  Practice i2mo,     i   50 

Manual  of  Steam-boilers,  their  Designs,  Construction,  and  Operation -Svo,     5  00 
Wehrenfenning's  Analysis  and  Softening  of  Boiler  Feed-water  'Patterson)   Svo,     4  00 

Weisbach's  Heat,  Steam,  and  Steam-engines.     ^Du  Bois.j Svo,    5  00 

Whitham's  Steam-engine  Design Svo,     5  00 

Wood's  Thermodynamics,  Heat  Motors,  and  Refrigerating  Machines.  .  .Svo,    4  00 


MECHANICS   AND   MACHINERY. 

Bart's  Kinematics  of  Machinery 870,  2  50 

*  Bovey's  Strength  of  Materials  and  Theory  of  Structures   Svo,  7  50 

Chase's  The  Art  of  Pattern-making i2mo,  2  50 

15 


Church's  Mechanics  of  Engineering 8vo,  6  oo 

Notes  and  Examples  in  Mechanics 8vo,  2  00 

Compton's  First  Lessons  in  Metal-working lamo,  1  50 

Compton  and  De  Groodt's  The  Speed  Lathe lamo,  i  so 

Cromwell's  Treatise  on  Toothed  Gearing i2mo,  i  50 

Treatise  on  Belts  and  Pulleys i2mo,  i  50 

Dana's  Text-book  of  Elementary  Mechanics  for  Colleges  and  Schools.  .i2mo,  i  50 

Dingey's  Machinery  Pattern  Making i2mo,  2  00 

Dredge's   Record  of  the   Transportation  Exhibits  Building  of  the   World's 

Columbian  Exposition  of  1893 4to  half  morocco,  5  00 

Du  Bois's  Elementary  Principles  of  Mechanics : 

Vol.      I.     Kinematics 8vo,  3  50 

VoL    II.     Statics 8vo,  4  00 

Mechanics  of  Engineering.     Vol.    I Small  4to,  7  50 

Vol.  n Small  4to,  10  00 

Durley's  Kinematics  of  Machines 8vo,  4  00 

Fitzgerald's  Boston  Machinist i6mo,  i  00 

Flather's  Dynamometers,  and  the  Measurement  of  Power i2mo,  3  00 

Rope  Driving i2mo,  2  00 

Goss's  Locomotive  Sparks 8vo,  2  00 

Locomotive  Performance 8vo,  5  00 

*  Greene's  Structural  Mechanics 8vo,  2  50 

Hall's  Car  Lubrication i2mo,  i  00 

Hobart  and  Ellis's  High-speed  Dynamo  Electric  Machinery.     (In  Press.) 

HoUy's  Art  of  Saw  Filinj; iSmo,  75 

James's  Kinematics  of  a  Point  and  the  Rational  Mechanics  of  a  Particle. 

Small  Svo,  2  00 

*  Johnson's  (W.  W.)  Theoretical  Mechanics i2mo,  3  00 

Johnson's  (L.  J.)  Statics  by  Graphic  and  Algebraic  Methods Svo,  2  00 

Jones's  Machine  Design: 

Part    I.     Kinematics  of  Machinery Svo,  i  50 

Part  II.     Form,  Strength,  and  Proportions  of  Parts Svo,  3  00 

Kerr's  Power  and  Power  Transmission Svo,  2  00 

Lanza's  Applied  Mechanics Svo,  7  50 

Leonard's  Machine  Shop,  Tools,  and  Methods Svo,  4  00 

*  Lorenz's  Modern  Refrigerating  Machinery.     (Pope,  Haven,  and  Dean.). Svo,  4  00 
MacCord's  Kinematics;   or.  Practical  Mechanism Svo,  5  00 

Velocity  Diagrams Svo,  1  50 

*  Martin's  Text  Book  on  Mechanics,  Vol.  I,  Statics i2mo,  i   25 

*  Vol.  2,  Kinematics  and  Kinetics  .  .l2mo,  1  50 

Maurer's  Technical  Mechanics Svo,  4  00 

Merriman's  Mechanics  of  Materials Svo,  5  00 

*  Elements  of  Mechanics i2mo,  i   00 

*  Michie's  Elements  of  Analytical  Mechanics Svo,  4  00 

*  Parshall  and  Hobart's  Electric  Machine  Design 4to,  half  morocco,  12  50 

Reagan's  Locomotives :  Simple,  Compound,  and  Electric.     New  Edition. 

Large  i2mo,  3  5o 

Reid's  Course  in  Mechanical  Drawing Svo,  2  00 

Text-book  of  Mechanical  Drawing  and  Elementary  Machine  Design. Svo,  3  00 

Richards's  Compressed  Air i2mo,  i  50 

Robinson's  Principles  of  Mechanism Svo,  3  00 

Ryan,  Norris,  and  Hoxie's  Electrical  Machinery.     Vol.  I Svo,  2  50 

Sanborn's  Mechanics :  Problems Large  i2mo,  i  50 

Schwamb  and  Merrill's  Elements  of  Mechanism Svo,  3  00 

Sinclair's  Locomotive-engine  Running  and  Management i2mo,  2  00 

Smith's  (O.)  Press-working  of  Metals Svo,  3  00 

Smith's  (A.  W.)  Materials  of  Machines i2mo,  i  00 

Smith  (A.  W.)  and  Marx's  Machine  Design , Svo,  3  00 

Sorel's    Carbureting   and    Combustion   of   Alcohol  Engines.     (Woodward  and 

Preston.) Large  Svo,  3  o« 

16 


Spangler,  Greene,  and  Marshall's  Elements  of  Steam-engineering 8vo.    3  00 

Thurston's   Treatise  on  Friction  and  Lost  Work  in    Machinery  and    Mill 

Work 8,,o^    3  00 

Animal  as  a  Machine  and  Prime  Motor,  and  the  Laws  of  Energetics.  i2mo,     i  00 
Tillson's  Complete  Automobile  Instructor i6mo 


SO 


Morocco,  2  00 

Warren's  Elements  of  Machine  Construction  and  Drawin^ 8vo,    7  50 

Weisbach's  Kinematics  and  Power  of  Transmission.    (Herrmann — Klein. ).8vo.    5  00 
Machinery  of  Transmission  and  Governors.       (Herrmann— Klein.)  .8vo.     5  00 
Wood's  Elements  of  Analytical  Mechanics 


ovo,  3  00 

Principles  of  Elementary  Mechanics i2mo,  i  25 

Turbines 8^o|  2  50 

The  World's  Columbian  Exposition  of  1893 4to  i  00 

MEDICAL. 

*  Bolduan's  Immune  Sera l2mo,  1  50 

De  Fursac's  Manual  of  Psychiatry.     (Rosanoff  and  Collins. ).    ..    Large  i2mo'.  250 

Ehrlich's  Collected  Studies  on  Immunity.     (Bolduan.) 8vo,  6  00 

*  Fischer's  Physiology  of  Ahmentatioii Large  l2mo,  cloth,'  2  00 

Hammarsten's  Text-book  on  Physiological  Chemistry.     (Mandel.) 8vo,  4  00 

Lassar-Cohn's  Practical  Urinary  Analysis.     (Lorenz.). i2n:o,'  r  00 

*  Pauli's  Physical  Chemistry  m  the  Service  of  Medicine.      (Fischer. ) .  .  .  .  i2mo,  i  25 

*  Pozzi-Escot's  The  Toxins  and  Venoms  and  their  Antibodies.     (Cohn.  1.  i2mo,  i  00 

Rostoski's  Serum  Diagnosis.     (Bolduan.) i2mo',  i  00 

Salkowski's  Physiological  and  Pathological  Chemistry.     (Orndorff.) 8vo',  2  50 

*  Satterlee's  Outlines  of  Human  Embryology i2mo,  1  25 

Steel's  Treatise  on  the  Diseases  of  the  Dog gvo,  3  50 

Von  Behring's  Suppression  of  Tuberculosis.      (Bolduan.) i2mo,  i  00 

Woodhull's  Notes  on  Mihtary  Hygiene i6mo,  r  50 

*  Personal  Hygiene "    ,2jno|  ^  ^^ 

Wulling's  An  Elementary  Course  in  Inorganic  Pharmaceutical  and  Medical 


Chemistry 


.  i2mo,    2  00 


METALLURGY. 


Betts's  Lead  Reflning  by  Electrolysis.     (In  Press.) 
Egleston's  Metallurgy  of  Silver,  Gold,  and  Mercury  ■ 

V°l-    I-     Silver 8vo,  750 

Vol.  II.     Gold  and  Mercixry g^^^  ^  2^ 

Goesel's  Minerals  and  Metals:     A  Reference  Book - .  .'.  .  i6mo^  mor'  3  00 

*  Iles's  Lead-smelting \^^^^  ^  ^^ 

Keep's  Cast  Iron g^^^  ^  50 

Kunhardt's  Practice  of  Ore  Dressing  in  Europe 8vo,  i   ro 

Le  Chateher's  High-temperature  Measurements.  (Boudouard— Burgess.)i2mo,'  3  00 

Metcalf's  Steel.     A  Manual  for  Steel-users.  .     .                                             i2mo'  2  00 

MiUer-s  Cyanide  Process ■.■.■;■■■.■  ,^^^[  ^  „„ 

Minet's  Production  of  Aluminum  and  its  Industrial  Use.     (Waldo.). . .  .  ramo.  2  50 
Robine  and  Lenglen's  Cyanide  Industry.     (Le  Clerc).  .....                        gvo' 

Smith's  Materials  of  Machines 

™,        .      ,    -.        .  i2mo,     I  00 

Thurston  s  Materials  of  Engineering.     In  Three  Parts.  «vn      a  »„ 

Part    n.     Iron  and  Steel .'...'.'.' gH'  I 

Part  m.     A  Treatise  on  Brasses,  Bronzes,  and  Other  Alloys  and  their 
Constituents „ 

Ulke's  Modern  Electrolytic  Copper  Refining ...................      '  sTo,    3  00 

MINERALOGY. 

Barringer's  Description  of  Minerals  of  Commercial  Value.    Oblong,  morocco      2  =^0 
Boyd  s  Resources  of  Southwest  Virginia  o     ' 

ovo,    3  00 

17 


4 

oo 

5 

oo 

50 

1 

oa 

I 

25 

5 

oo 

Boyd's  Map  of  Southwest  Virignia Pocket-book  form.     2  oo 

♦Browning's  Introduction  to  the  Rarer  Elements 8vo,    i   50 

Brush's  Manual  of  Determinative  Mineralogy.     (Penfield. ) 8vo,    4  00 

Chester's  Catalogue  of  Minerals. 8vo,  paper,  i  00 

Cloth,    I  25 

Dictionary  of  the  Names  of  Minerals 8vo,     3  50 

Dana's  System  of  Mineralogy Large  8vo,  half  leather,  12  50 

First  Appendix  to  Dana's  New  "  System  of  Mineralogy." Large  8vo,     i  00 

Text-book  of  Mineralogy 8vo,    4  00 

Minerals  and  How  to  Study  Them i2mo,    i  50 

Catalogue  of  American  Localities  of  Minerals Large  8vo,     i  00 

Manual  of  Mineralogy  and  Petrography i2mo     2  00 

Douglas's  Untechnical  Addresses  on  Technical  Subjects i2mo,    i  00 

Eakle's  Mineral  Tables 8vo,     i   25 

Egleston's  Catalogue  of  Minerals  and  Synonyms 8vo,    2  50 

Goesel's  Minerals  and  Metals ;     A  Reference  Book i6mo,mor.     3  00 

Groth's  Introduction  to  Chemical  Crystallography  (Marshall) i2mo,     i  25 

Iddings's  Rock  Minerals 8vo,    s  00 

Johannsen's  Key  for  the  Determination  of  Rock-forming  Minerals   in   Thin 
Sections.     (In  Press.) 

*  Martin's  Laboratory  Guide  to  Qualitative  Analysis  with  the  Blowpipe.  I2mo,        60 
Merrill's  Non-metallic  Minerals.   Their  Occurrence  and  Uses 8vo, 

Stones  for  Building  and  Decoration   ..  8vo, 

*  Penfield's  Notes  on  Determinative  Mineralogy  and  Record  of  Mineral  Tests. 

8vo,  paper, 
Tables  of  Minerals • 8vo, 

*  Richards's  Synopsis  of  Mineral  Characters,. i2mo.  morocco, 

*  Ries's  Clays.  Their  Occurrence.  Properties,  and  Uses 8vo, 

Rosenbusch's   Microscopical   Physiography   of   the    Rock-making  Minerals. 

(Iddings.) 8vo, 

*  Tillman's  Text-book  of  Important  Minerals  and  Rocks 8vo, 

MINING. 

Beard's  Mine  Gases  and  Explosions.     (In  Press.) 

Boyd's  Resources  of  Southwest  Virginia ; 8vo, 

Map  of  Southwest  Virginia Pocket-book  form, 

Douglas's  Untechnical  Addresses  on  Technical  Subjects i2mo, 

Eissler's  Modern  High  Explosives 8-o, 

Goesel's  Minerals  and  Metals;     A  Reference  Book i6mo,  mor. 

Goodyear's  Coal-mines  of  the  Western  Coa-,t  of  the  United  States i2mo, 

Ihlseng's  Manual  of  Mining 8vo, 

*  Iles's  Lead-smelting i2mo, 

Kunhardt's  Practice  of  Ore  Dressing  in  Europe 8vo, 

MiUer's  Cyanide  Process i2mo, 

O'Driscoll's  Notes  on  the  Treatment  of  Gold  Ores 8vo, 

Robine  and  Lenglen's  Cyanide  Industry.     (Le  Clerc.) 8vo, 

Weaver's  Military  Explosives 8vo, 

Wilson's  Cyanide  Processes i2mo, 

Chlorination  Process.  .  -, limo. 

Hydraulic  and  Placer  Mining.     2d  edition,  rewritten i2mo. 

Treatise  ojq  Practical  and  Theoretical  Mine  Ventilation T2mo, 

SANITARY  SCIENCE. 

Bashore's  Sanitation  of  a  Country  House i2mo,    i  00 

*  Outlines  of  Practical  Sanitation i2mo,    i  25 

Folwell's  Sewerage.     (Designing,  Construction,  and  Maintenance.) 8vo,    3  00 

Water-supply  Engineering.  . , 8vo,    4  00 

18 


3 

00 

2 

00 

I 

00 

4 

00 

3 

00 

2 

50 

5 

00 

2 

50 

I 

50 

I 

00 

2 

00 

4 

00 

3 

00 

I 

50 

I 

50 

2 

50 

I 

25 

2 

OO 

I 

SO 

2 

50 

I 

00 

1 

50 

3 

00 

7 

50 

4 

00 

I 

25 

2 

00 

2 

00 

I 

25 

I 

50 

I 

00 

Fowler's  Sewage  Works  Analyses i2niD, 

Fuertes's  Water  and  Public  Health i2mo, 

Water-filtration  Works i2mo, 

Gerhard's  Guide  to  Sanitary  House-inspection i6mo, 

Sanitation  of  Public  Buildings 12mo, 

Hazen's  Filtration  of  Public  Water-supplies 8vo, 

Leach's  The  Inspection  and  Analysis  of  Food  with  Special  Reference  to  State 

Control 8vo, 

Mason's  Water-supply.  (Consideredprincipally  from  a  Sanitary  Standpoint)  8vo, 

Examination  of  Water.     (Chemical  and  Bacteriological.) i2mo, 

*  Merriman's  Elements  of  Sanitary  Engineering 8vo, 

Ogden's  Sewer  Design i2mo, 

Prescott  and  Winslow's  Elements  of  Water  Bacteriology,  with  Special  Refer- 
ence to  Sanitary  Water  Analysis i2mo, 

*  Price's  Handbook  on  Sanitation i2mo, 

Richards's  Cost  of  Food.     A  Study  in  Dietaries i2mo, 

Cost  of  Living  as  Modified  by  Sanitary  Science i2mo,    i  00 

Cost  of  Shelter i2mo,     i  00 

Richards  and  Woodman's  Air.  Water,  and  Food  from  a  Sanita-y  Stand- 
point  8vo,    2  00 

*  Richards  and  Williams's  The  Dietary  Computer 8vo,     i  50 

Rideal's  S;wage  and  Bacterial  Purification  of  Sewage 8vo,     4  00 

Disinfection  and  the  Preservation  of  Food 8vo,    400 

Turneaure  and  Russell's  Public  Water-supplies 8vo,    s  00 

Von  Behring's  Suppression  of  Tuberculosis.     (Bolduan.) • i2mo,     i  00 

Whipple's  Microscopy  of  Drinking-water 8vo,    3  50 

Wilson's  Air  Conditioning.     (In  Press.)  ^ 

Winton's  Microscopy  of  Vegetable  Foods 8vo,    7  50 

WoodhuU's  Notes  on  Military  Hygiene iCmo,    1  50 

*  Personal  Hygiene i2mo,     i  00 


MISCELLANEOUS. 

Association  of   State    and  National  Food  and  Dairy  Departments  (Interstate 
Pure  Food  Commission) : 

Tenth  Annual  Convention  Held  at  Hartford,  July   17-20,  1906.  ...8vo,     3  00 
Eleventh    Annual    Convention,    Held  at   Jamestow^n    Tri-Centennial 
Exposition,  July  16-19,   1907.     (In  Press.) 
Emmons's  Geological  Guide-book  of  the  Rocky  Mountain  Excursion  of  the 

International  Congress  of  Geologists Large  Evo,    i  50 

Ferrel's  Popular  Treatise  on  the  Winds 8vo,     4  00 

Gannett's  Statistical  Abstract  of  the  World    24mo,        75 

Gerhard's  The  Modem  Bath  and  Bath-houses.     (In  Press.) 

Haines's  American  Railway  Management i2mo,    2  50 

Ricketts's  History  of  Rensselaer  Polytechnic  Institute,  1824-1804.  .Small  8vo,    3  00 

Rotherham's  Emphasized  New  Testament Large  8vo,    2  oo 

Standage's  Decorative  Treatment  of  Wood,  Glass,  Metal,  etc.     (In  Press.) 

The  World's  Columbian  Exposition  of  1893 4to,    i  00 

Winslow's  Elements  of  Applied  Microscopy l2mo,     i  50 


HEBREW  AND   CHALDEE  TEXT-BOOKS. 

Green's  Elementary  Hebrew  Grammar r2mo,  i  25 

Hebrew  Chrestomathy 8vo,  2  00 

Gesenius's  Hebrew  and  Chaldee  Lexicon  to  the  Old  Testament  Scriptures. 

(Tregelles.) Small  4to,  half  morocco,  5  00 

Letteris's  Hebrew  Bible 8vo,  2  25 

19 


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